Wiki Documentation and correct coding question

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For many months I've sent out training material to our group. Information about why ICD10 is important, how to look up codes, how to document and more. I've probably written over 70 pages worth of how-tos and other guides over the course of a 9 months.

As we get closer to October 1st, I've heard very little feedback from anyone in the office. Very few questions or acknowledgements...and ICD10 is a big change. I expected something. Obviously I'm a little worried.

I code in our office and am not worried about myself. I'm worried about our documentation.

Our EHR allows the staff to choose a description, if they choose a description that appears in the final office note under Assessment of "Pressure Ulcer, Stage 1, unspecified leg"...but their earlier exam shows that the pressure ulcer occurred on the right thigh....can I code based off of that? Or do I need to send those back to the provider for clarification since the Assessment the provider signed off on says "unspecified leg"?

I hope that question makes sense.
 
I would definitely ask for clarification of site and stage!! This will cover all bases (including you) and keep the account from being called into question by a compliance auditor. Better to be safe than sorry :)
 
I was thinking the same thing honestly, but I feel like it never hurts to ask and get more opinions.

I've gotten feedback from two employees. Two. That's it. I can't force them to learn anything they don't want to and no one else is forcing them to.

But...if they don't want to document correctly the first, second and third time...I'm sure by the fourth time I ask them for clarification and addendums they will catch on. I hope.
 
Wow, I can't believe you are having such a hard time. Don't worry, things should turn around for you when claims are denied due to poor documentation, noncompliance with ICD-10 codes, and payment is not rendered. You know that the almighty dollar is what drives the work. My coding is inpatient based, so within the last two months, there has been an upswing on what constitutes as a relevant and code-able diagnosis. I have spent ALOT of time writing extra queries for documentation clarification just to cover myself. Some of the physicians will not even carry over the diagnosis/es into the discharge summary which is pretty much supercedes everything other document in the chart. I still get little cooperation, and a couple of physicians will even leave snarky comments on the query like "read the progess notes, I documented there" or "not sure"...how are you not sure if you've been documenting in progress notes from day one???? This switch will surely be interesting, that's for sure.

Good luck!
 
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