Question ICD-10 codes in progress note vs codes on claim

maryek28@outlook.com

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The software that we use allows the provider to add diagnosis codes to a section of the progress note, however a lot of the time the codes are not correct (eg. documentation says "Diabetes Type I", but provider lists code for DM type II). My supervisor insists that I need to contact the provider each time this happens and ask him to edit the DX code section of the note to have the correct codes. The provider doesn't appreciate this since it happens a lot. To me, this seems unnecessary since I always put the correct codes on the claim (I am a CPC). My question is; would an auditor really care about the codes listed in this section of the progress note or would they just be comparing the documentation with the codes that we submitted on the claim?
 

thomas7331

True Blue
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Every auditor I've ever known will compare the documentation with the claim. The code choices made by a provider are notoriously inaccurate, and auditors will disregard these. Per ICD-10 guidelines, providers are to document the patient diagnosis in the record in their own words, and this should be the basis of the code choice for reporting the claim. The fact that there are incorrect codes in the record is not an issue for auditors. I would not trouble the providers with this unless there is something that is incorrect or unclear in the documentation that requires that they amend the record in order for you to be able to code accurately.
 

RDK720

Networker
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In our Dept, reported information on a claim, such as CPT and diagnoses, must be supported by the documentation. If they do not match, we always contact the provider to confirm and this acts as a reminder to submit accurate information.
 
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I agree - as long as it states in the note DM I, it would not matter to an auditor if the physician then selected the incorrect code.
It is certainly not a "best practice" for the physicians to always select the incorrect codes and they might need some reminder education about it. I know I see all the time clinicians selecting the easiest code to find, not the most accurate code (like generic abnormal PAP smear instead of finding the code for abnormal cervical PAP with LGSIL finding). That's why I personally think the clinicians should be practicing medicine and not coding.
 

KellyLR

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Hi,

Been an Auditor going on 10 years. I couldn't care less if I see codes embedded by others or even Minnie Mouse! What I go by is provider documentation as the provider owns what is documented and that documentation must meet medical necessity and accurate reportable coding. If the MR contraindictory or just plan lacking in supportable, reportable content, I fail the record. Not our problem if the provider isn't trained to produce coherent notes.
 

maryek28@outlook.com

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Hi,

Been an Auditor going on 10 years. I couldn't care less if I see codes embedded by others or even Minnie Mouse! What I go by is provider documentation as the provider owns what is documented and that documentation must meet medical necessity and accurate reportable coding. If the MR contraindictory or just plan lacking in supportable, reportable content, I fail the record. Not our problem if the provider isn't trained to produce coherent notes.
Thanks! So we shouldn't worry about asking the provider to edit the codes he selects as long as the codes I put on the claim match the documentation?
 

KellyLR

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If the provider does the coding and not the coder, then whoever or whatever department responsible for reviewing what was coded has the responsibility to report inaccurate coding. I've worked with plenty of providers of all types to experience that some of them go by a list formulated for them and they don't necessarily know or want to to know the entire coding series for a code.

It is a responsibility of a coding supervisor or some other designated credentialed professional to inform the provider of the coding discrepancy. A non-leading query is very helpful. Asking to amend their documentation may be in order too. I've audited places that leave the coding selection to the provider and the coders audit records. Nightmare sometimes.

However, the medical record documentation by provider drives the coding. If you have to re-code that medical record, then that is what you do to submit a clean claim. I have re-coded many records before submission and post audited records to re-submission. It can be pain! Forget asking the provider to edit their coding, educate them on proper documentation and coding. When the provider takes notice (I love this part) then you can advise them through documentation evidence why the coding is not accurate and do that in writing.
 
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