Wiki Having more than one coder involved in coding a patients record

[justjoan]

I am a CPC and I do ED Coding for both facility and professional. We also work our claim edits for the patients that we code. Is it appropriate if I coded a patients record both procedure and diagnosis to have another coder get involved in that chart. Example: I coded out a 99282 and the patient also had a chest x-ray done which would require a 25 modifier to be added to the 99282. Is it appropriate for another coder to add the 25 to the procedure code I assigned. I don't think it is and I don't want to risk my certification if someone steps else gets involved. Is there any documentation to back up this theory?

 

[KellyLR]

I am a CPC and I do ED Coding for both facility and professional. We also work our claim edits for the patients that we code. Is it appropriate if I coded a patients record both procedure and diagnosis to have another coder get involved in that chart. Example: I coded out a 99282 and the patient also had a chest x-ray done which would require a 25 modifier to be added to the 99282. Is it appropriate for another coder to add the 25 to the procedure code I assigned. I don't think it is and I don't want to risk my certification if someone steps else gets involved. Is there any documentation to back up this theory?

Good question Joan. One would think the coding group would have respect. However, talk to your supervisor for clarification. The other coder may be instructed to look for procedures and E/M coding and missing -25. All you can do is keep a record of every record you code and no PI as a record of what you coded. If something comes back, you at least have this to fall to.
Good Luck!

 

[SharonCollachi]

Was it a mistake on your part, or was the chest xray added on later in the day? I prefer to have my mistakes pointed out to me, so I know what I'm doing wrong. What is the policy where you work?

 

[thomas7331]

Large organizations do often have multiple coders, billers and/or charge entry personnel involved in a single record due to the process flows that are set up. There aren't any regulations that prohibit this since the responsibility for the accuracy of the claim ultimately falls to the organization that owns and is financially responsible for it. Organizations may assign their coders' work as they see fit in order to best accomplish this. All compliant electronic records and billing systems these days have audit trails that will show each user who has accessed or changed the patient's record at any given time, so there should never be any question as to the individual responsibility of a given coding assignment, so I wouldn't be concerned that another coder's changes might fall back on you.

But I agree with the post above that if you have concerns about having seen another employee altering your coding, it's something you should discuss with a supervisor or manager. Managers rely on staff to be their 'eyes and ears' on the front lines, and need to be aware of what you're seeing. It may be nothing of concern, or on the other hand, another employee could be acting out of the scope. Or it could also be an opportunity for improved efficiency if there are multiple coders needlessly reviewing the same records when it could be done by one. Hope this helps some.

 

[kdlberg]

It could also be used as a training opportunity. For instance, if one person is consistently forgetting modifier -25 (as evidence by the second person having to add it back on a regular basis), then maybe the first coder needs a quick refresher on using -25. Or if some coders are still using modifier -59 when one of the X subset would be more appropriate, it's time to go over those again.