Wiki Documentation requirements

atitus

Guest
Messages
5
Location
Fisher, TX
Best answers
0
The CPC's often go into charts and add addendums in order to document any code corrections they make to what the provider actually coded in the chart. The coders have been documenting the code entered by the provider, the complete description of the code, the code they replaced it with and that codes entire description and they document the reason the code was changed.

For example:
Added diagnosis codes L27.0 (generalized skin eruption due to drugs and medicaments taken internally) and T36.0X5A (adverse effect of penicillins, initial encounter) per note.

Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9 (acute upper respiratory infection, unspecified)



The coders spend a lot of time spelling it all out and I wonder if that extensive of documentation is really necessary. Could the documentation just say
Added diagnosis codes L27.0 and T36.0X5A per note
Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9

Do we really have to provide the complete description of the code to be compliant?

Thanks for your input.
 
A CPC should never enter information into a patient chart document. The codes on the claim do not need to match the codes in the note as long as the Diagnosis number entered on the claim can be verified with the documented diagnosis rendered by the provider. There is no need to amend the chart note.
 
Last edited:
Debra,
thank you so much for your response. I find it interesting, and I wonder if I didn't articulate my question well. We had an outside auditor come in a few years ago and we were told (and got dinged) that the diagnoses in the chart should match the diagnoses billed. Our Internal auditor also stated the billing should match the chart according to her CPMA training.
In our office, coders do not code per chart notes. The provider chooses the diagnosis codes (quickly to be charge passed electronically) and we often have to addend the notes with code corrections below the codes they chose.
 
Last edited:
I think the auditor passed on mis information. The code on the claim must match the rendered diagnosis in the chart note. This doe not need to be the same code chosen by the provider. There is no way an auditor should ding you on an audit as long as the billed code matches the rendered diagnosis. Coders should... no MUSt code from a review of the chart notes, There should be no exceptions. The chart does not have need to be amended just because a numeric code is different as long as the code matches the render diagnosis. Coding clinic 1st quarter 2012 is an excellent resource for this issue. They state that a provider cannot chose a diagnosis code to be the rendered diagnosis, the provider is required to render the diagnosis in their own words. It goes further to state that coding is to be performed by professionally trained coding staff. You can go to the AHA store and purchase individual copies of a coding clinic.
 
Top