Wiki Coders having access to change the EMR

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KimBest

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Our question is with the new upgrade to our EMR, the doctors now have to select the ICD-9 codes before they can finish their note. When we are coding the visit, we come up with a different code due to coding guidelines, such as they will put a code for diabetes and then a code for an ulcer instead of one combined code. One of our physicians wants the coders to go into the record and amend the codes so that the claim and the record match. Is there somewhere that we can get some guidance on this issue? I'm concerned that coders should not be changing or have access to change the medical record. Help? Suggestions?:confused:
 
Our practice had been putting codes in EMR since I have been with them. I pick and choose exactly which codes are relevant and which ones to put on the claim (he includes any and every code even when not relevant). However, I never change a code. We use few tickets, so I'll write a note like "can't code a rule-out diagnosis" or something of that nature. He corrects it in the system and then I can put the correct code on the claim that matches.
 
It seems there are two questions here - 1) changing a code, and 2) changing code sequencing.

I would never recommend a coder (or anyone other than the provider) change the code itself, unless the provider has been queried/questioned, and the provider gives the coder a different code to use to describe the diagnosis.

If sequencing the diagnosis codes is the issue, then, yes, I would be comfortable with the coder re-ordering the sequence of the codes. The provider may not always be familiar with coding conventions or rules. I code for wound care and have been for many years and see the scenario you describe frequently. Most payors want the ulcer sequenced first, then the diabetes, even though ICD-9-CM states we should code the underlying etiology first. Love this job!
 
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