Hello Everyone!
I have just recently started a new Coding job as a CPC-A. The new position I accepted gives me only "Rounding" sheets from the physicians that mark off which E/M code they did, and the diagnosis relevant to that patient. However, I have limited access to Medical Records for the Hospital AND Clinics to double check the diagnosis and to retrieve additional information. Sometimes when I check the medical records I see that the notes have not even been started, and there is NOTHING for me to go off of. Too often I receive rounding sheets for patients that have lengthy stays in the hospital from complications and rounding sheets marked "DM Type 2 Uncontrolled" and no additional information. Especially with the ICD-10-CM being implemented, I find it nearly impossible to code these rounding sheets and physicians have already declined to be more specific. If there is not any notes in the computer from these physicians, Im not supposed to code it right????
I have just recently started a new Coding job as a CPC-A. The new position I accepted gives me only "Rounding" sheets from the physicians that mark off which E/M code they did, and the diagnosis relevant to that patient. However, I have limited access to Medical Records for the Hospital AND Clinics to double check the diagnosis and to retrieve additional information. Sometimes when I check the medical records I see that the notes have not even been started, and there is NOTHING for me to go off of. Too often I receive rounding sheets for patients that have lengthy stays in the hospital from complications and rounding sheets marked "DM Type 2 Uncontrolled" and no additional information. Especially with the ICD-10-CM being implemented, I find it nearly impossible to code these rounding sheets and physicians have already declined to be more specific. If there is not any notes in the computer from these physicians, Im not supposed to code it right????