Wiki Correct coding

[richelle25]

Good Morning,
I have a question, hope somebody can help. Our office uses electronic records/charts. When the office note is created by the physician, it automatically creates an invoice. Then when the invoice is opened, by the CPC biller it begans the actual charge. Our CPC biller reads the office note and if any errors are made she corrects the charge, the office note itself is not changed. The corrections are never major corrections, such as a procedure documented but the code not captured or if the patient is an established patient and the provider codes the charge as a new patient. My question is since our biller has the CPC credentials, does she have the authority to correct the charge and submit for payment. Also does the original note have to been changed by the provider. What would be the risk in an audit if we did not change the note to match what is billed? Once again we are not billing incorrectly, just charging what is correct.

 

[mitchellde]

Yes the coder can change any code as long as she does so based on the documentation. As long as this is how it is done the the claim does match the record, just because the codes are different is not an issue as long as the note matches the claim. The numeric code should not even be in the medical record document, and if this is an issue then you can have your vendor turn off that part. If your provider is going to spend time coding and then your coder is also spending time coding then there is duplication of effort. If the provider spends just 2 minutes per patient coding, and sees 20 patients per day then you have given back 40 minutes. This is really something to consider with ICD-10 CM on the horizon.
If you do not change the claim to match what is in the note the risk in a audit is huge! The original note as far as the narrative must always match the claim, it is not based on the code in the note.

 

[richelle25]

Thank you so much for your response. I completely agree with you, unfortunatley there is a conflict in the office regarding this issue. By any chance do you know if I could locate this in "writting" stating this as official? Thanks again!

 

[mitchellde]

I know that there was a piece in the 2012 coding clinic either 1st quarter or second quarter, and it was quoted last summer in one of the forums, or you will have to purchase the coding clinic. also in the coding guidelines it states:
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

there are probably many other sources of information regarding this.

 

[mitchellde]

I know that there was a piece in the 2012 coding clinic either 1st quarter or second quarter, and it was quoted last summer in one of the forums, or you will have to purchase the coding clinic. also in the coding guidelines it states:
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

there are probably many other sources of information regarding this.

 

[richelle25]

Thank you so much for your input! Have a great day