Wiki EMR Documentation - When a provider documents

[jheiser]

When a provider documents the charge through the EMR and according to the billing (certified coder) the provider has may an error with either the CPT or ICD-9 code, is it legally ok for the coder to change the codes as long as there is clear documentation in the medical record as to what is being done or does this need to be changed and signed by the provider of the service?

 

[mitchellde]

Yes, not only can a coder change the codes, but they must change them to match the documentation. As long as you use the guidelines coupled with the information in th documentation there is nothing illegal about that. However to just use the codes provided by the physician, especially if you know they are wrong could be potentially fraudulent.