General Questions on Inpatient Coding Using a CAC Program

[rshindel]

Hi -

I am gathering data on how different EMR systems using CAC (Computer Assisted Coding) to assign diagnosis codes. I am looking for information on the following:

1) Does your system assign a principal or primary diagnosis code to the medical record or is up to the coder to determine this after reviewing the medical record?
2) Does your system provide any code sequencing or is that up to the coder?

Thanks in advance for your responses.

Rebecca Shindel

diagnosis codes, diagnosis coding

 

[TThivierge]

Coding Research

Hi

I work mostly with outpatient FM billing setting but do some inpatient billing too. Our physicians assign the diagnosis & CPT codes in line with their documentation; the coder reads the record documentation to ensure he or she selects the correct diagnosis. At times coders must use the query process. Also the coder ensure the billing of CPT and Dx codes selected by physician are linked properly per medical necessity. We strive for clean correct claims; thus no denials. Also the coders ensure the claim is set up correctly on the claim and sequencing is done right per payer's regulations.


T Thivierge

diagnosis codes, diagnosis coding