Who is responsible for the final diagnosis that are used for an E/M visit? If a coder is reviewing documentation prior to the charge being sent and notices a diagnosis error, would/should/could the coder update the dx or is this the responsibility of the provider as the HCFA does state ultimately the provider is responsible. Thank you for any advice.
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Wiki E/M diagnosis
- Thread starter smithca
- Start date
I assign the diagnosis codes for my physicians' E/M visits based on the documentation from the visit. I'm the one who knows the coding rules and guidelines. The EMR system has the physician pick a code, but I always review it and update if needed.
Physicians aren't required to pick code - they are required to have appropriate documentation, so that codes can be assigned.
In some offices the physicians do the coding and any changes are made by the physician. That environment would not be my cup of tea - they're paying me to be a coder and ensure that codes are supported by documentation and accurate according to the guidelines.
If the physician is doing all the coding and limits my ability to apply corrections, why am I even there? That's my hot take, I guess.
Yes, as @sls314 stated, the answer could vary based on your employer. While ultimately, the provider is responsible for all claims submitted under their name, in most employers, a coder can change a code picked by a provider. A coder is trained to take the words in the documentation and translate that into CPT, ICD10 and HCPCS. It shouldn't matter what code the clinician assigned - the actual words matter. A coder cannot assign codes when the words are not there to translate. For example - if physician writes "pharyngitis for 3 days" and assigns J02.0 (streptococcal pharyngitis), and nothing else in the record supports streptococcal pharyngitis, the coder should correct the billing to J02.9 acute pharyngitis, unspecified.
I'm with Susan on this - why have a coder review it if they cannot correct it?
I'm with Susan on this - why have a coder review it if they cannot correct it?
amyjph
True Blue
It depends on the policy and procedure of the practice or facility. I have seen where some providers refuse to allow anyone to change their codes.
Some places have a query system where it must be sent back before changes can be made to confirm.
As stated above, the provider is ultimately responsible. If you are talking about within the documentation itself, the coder cannot do that. If you are talking within the billing system and/or on the claim, it depends.
Some places have a query system where it must be sent back before changes can be made to confirm.
As stated above, the provider is ultimately responsible. If you are talking about within the documentation itself, the coder cannot do that. If you are talking within the billing system and/or on the claim, it depends.