Wiki Clinic coding question

[Dfreddie]

If the provider documents in their note that a procedure was performed, for example they froze 10 warts; can the coder enter the procedure code or does the provider need to have the order entered for that procedure in order to code it?

I have situations where the provider will enter 17110 x10 - which obviously is incorrect - can I change that w/o the provider re-entering that order?

I'm being told that if the procedure is documented in that clinic note, then we can adjust/add the CPT entries to match what is performed. Which makes sense, but at the same time I have doubts.

 

[cgaston]

Selecting the correct code for the documented service is exactly what we're trained to do!

ETA: The physicians are trained to provide services, not bill for them. My employer knows that coders have more knowledge regarding correct code selection so we are allowed to correct a physician's code if appropriate.

 

[Dfreddie]

Thank you. That's what I was looking for. I just needed some back up