EMR/EHR Code Auditing

demorrison

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What is the standard of practice in using computerized coding, i.e. electronic medical records or coding software, in terms of being monitored? Are we letting the software code for the doctors and sending it on as is, or going over it to make sure it is correct? If so, how are we managing our time to go through the process of checking the doctors work? Thank you!
 

Sandymit25

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We have had an emr with coder since 2006. My opinion You Should always have someone compare the charge to the visit note. Emrs cant account or discount for medical necessity or medical decision making but they definitely help speed up the process of being able to see if what was coded is substantiated in the patients chart...(ekgs, ua, removals e/m bullet points etc)
 

Dduke

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i do have a question in regards to X-ray documentation (reports), our physicians are inquiring about dictating a separate report for the xray. Some of our physicians say that a separate report needs to be dictated and others say that they only need to mention this in the office visit notes.
thank you for all of your help in this matter. If there is a policy about this to please let me know all of your help is appreciated.
 

merielin

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I would like to know what the rule is on this: A provider documents an encounter with pertinent HPI, ROS, Exam, etc., but during the course of the encounter note doesn't document to the highest level of specificity regarding the diagnosis. Now he or she comes to the step in EHR charge capture where he or she selects the proper diagnosis (from a provider perspective). The diagnosis code selected by the provider is far more specific. For example, the diagnosis code may select the type of infection, the type of diabetes and its complication, or the name of the disease process he or she arrived at.

My question is, when auditing this note for proper coding, does the provider's documentation need to specifically state these things before arriving at the assessment part (where our EHR lists the diagnosis based on the code selected by the provider)? Or is it assumed (such a scary word in an audit) that when the provider selected the diagnosis code, he or she intended that further specificity to round out the documentation?

I am leery of shrugging my shoulders and saying, "Doctor knows best," but I also need some ground to stand on when going to the provider to ask for more clarity in his or her documentation.

Please help!

Meri, CPC, CEMC
 
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.

to
demorrison

yes it ok to use softwares to do coding but the code has to be rechecked by a coder .....

As i do as a coder..... i audit EnM charts which are already coded.
 

demorrison

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how do you audit the charts? I mean how do you come up with a routine, or do you audit every chart from every visit? with all of my other job duties there is no way that i could do each and every one. i'm just trying to come up with some sort of organized way to audit these charts correctly and then how to bring the information that i find to the doctors attention.
 
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I think the best practice is to document the specific diagnosis. However, many auditors accept the diagnosis because the provider took the time to select it. I feel this is questionable, because the provider may not be selecting the diagnosis according to coding guidelines.
 
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