tlindo1
Networker
I'm having an issue with some of my providers. I work in Behavioral Health and am encountering pushback from some of our providers and therapists. I am the outpatient coder for the facility, and we use My Avatar as our software. Our providers will enter the diagnosis codes themselves. As the coder, I review the notes to verify that the codes are correct and match the clinical documentation. There are many times when I find ICD-10 codes entered as "unspecified" when they can be more specific, should be combo codes, or are missing diagnosis codes per documentation, etc. Also, once the provider has finalized their visit note and entered the billing diagnosis codes, they cannot be changed for that claim.
As the medical coder, can I make changes to the ICD-10 codes that have been entered, since they use the pull-down list as their assessment diagnoses? The way I see it, if I were to add missing diagnoses, change a diagnosis code to a more specific one, or use codes that should be combo codes, I would, in a sense, be diagnosing the patient.
I also get pushback from some providers if I do make a change, as they feel that they have already entered the codes.
I am grateful for any advice or help.
As the medical coder, can I make changes to the ICD-10 codes that have been entered, since they use the pull-down list as their assessment diagnoses? The way I see it, if I were to add missing diagnoses, change a diagnosis code to a more specific one, or use codes that should be combo codes, I would, in a sense, be diagnosing the patient.
I also get pushback from some providers if I do make a change, as they feel that they have already entered the codes.
I am grateful for any advice or help.