I am a coder that was not allowed any part in EMR process and have not learned it yet. I am afraid that I have not been taught because I ask too many questions and questions why things are not more accurate..
However I was told to be prepared because that any codes picked by the physician even if an incorrect code. It is considered part of the actual chart documentation and is payable for that patient. Even with no dictation present, just the fact the code is listed. It is considered part of the meidical record and can and is legal to use as coding submissions even if a code was picked wrong and no dictation is there is to support it. The person even went to far to say to me that a physician can pick a male code for a female patient and it is not considered wrong!
RTR, RTT, CPC-PCS