Wiki Coding question-physician's written diagnosis

[vtc76]

I started my 1st ever coding job last month. If the physician's written diagnosis doesn't match the code he/she selected (i.e. "vaginal bleeding" - the doctor puts 625.8, but the correct code is 623.8) , can the coder change the code w/out notifying the physician? The place I currently work at just changes the code. However, at my internship earlier this year, the coders weren't allowed to change the code w/out first querying the doctor. In school, the instructor said don't change the code unless the provider changes it.

I'd really appreciate insight on this subject. Thanks.

 

[bkeeling]

code selection

First, I wish you the best of luck in your coding carrer. I would recommend that you do NOT change the physcian code selection. I would speak with the provider and let them know what you have determinded to be the more accurate code and show them why. Let the provider make that decision. You may want to clarify at that time if they want you to correct any codes that they have selected if you find a more correct code. I am hoping that you have the record for that date of service in question to use as your source of information. Always remember that it is the physician that is ultimately liable for the claim.

 

[JG24]

I anticipate that the reason you were not allowed to change the code during your internship was because that was a requirement of your school. I work with a lot of medical coding and billing students who are doing their extern/internships and are advised by the school that they are not allowed to change anything without permission. I concur with Belinda that it should be brought to the physician's attention and get him to agree with the change. Now is just as good a time as any to start querying the physicians regarding the rationale for the ICD-9 and CPT codes they select. Something tells me we will be doing a lot more of it when ICD-10 goes into effect. If we can get them to be more specific now, the better it will be for us later. Approach the physician with ICD-9 book in help and ask for his assistance rather than criticizing his choice. Maybe he marked the incorrect code by mistake. I also strongly encourage every coder to read the article in the August Coding Edge entitled "Knowing Your Liability for Aiding and Abetting" and share it with your Office Managers and physicians. This is without a doubt one of the best articles I have seen regarding exactly what our responsibility as coders is when there is any discrepancy/dispute regarding billing. I plan on sharing it with my friends who are billers and coders who have not joined AAPC yet. Good luck in getting the code corrected and good job in picking up on the fact it was the wrong diagnosis code.