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

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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?
 

RDK720

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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.
 

thomas7331

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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.
 

csperoni

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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.
 
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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.
 
Last edited:

Buff9786

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There are some EMR's that will allow you to turn off the codes that are attached to the display name so that codes do not show in the progress note. Being a doc, I can tell you that docs don't scroll and close enough is good enough when it comes to display names. In addition, IMO has very loose mapping from display names to codes and in some cases is straight out wrong. They have a very onerous review process and are hampered by little desire for institutional change or operational expertise. All that said, docs don't choose codes, they choose display names. The code attached is irrelevant from a clinical perspective and the docs don't know what they mean anyway.
 

KellyLR

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There are some EMR's that will allow you to turn off the codes that are attached to the display name so that codes do not show in the progress note. Being a doc, I can tell you that docs don't scroll and close enough is good enough when it comes to display names. In addition, IMO has very loose mapping from display names to codes and in some cases is straight out wrong. They have a very onerous review process and are hampered by little desire for institutional change or operational expertise. All that said, docs don't choose codes, they choose display names. The code attached is irrelevant from a clinical perspective and the docs don't know what they mean anyway.
Hi Buffy,
It isn't a provider's responsibility to code the record. Their responsibility is to document medically necessary care for the patient on the date of service rendered for that patient. However, with the use of ICD10 classification, a provider will need to provide specificity to diagnoses as CMS has directed the industry to steer clear of unspecified codes as much as possible and some unspecified codes will not work as 1st listed or principal diagnoses. Now, a provider who does code their codes themselves probably has some specific interest such as financial concern involved in the practice in which he/she practices. Bigger organizations who have coding staff should provide providers with training to let them know what coding specificity classifications are available that can be coded from their documentation in a non-leading way.

A group, small practice or even a big practice or organization shouldn't rely on EHR to do their coding for them. Verify your coding classifications in ICD10 book hardcopy and review the CPT and AHA clarifications along with ICD10 guidelines, then see what the payer or MAC has that they will pay for.
 

KellyLR

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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?
No, I wouldn't ask the provider to adjust EHR codes supplied as it is not necessary. What the coder applies to the claim from MR documentation is what gets the claim paid, not a EHR system.
 

kdlberg

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What the coder applies to the claim from MR documentation is what gets the claim paid, not a EHR system.
As long as the documentation supports whatever codes you bill, then you should be all right. As someone else mentioned, many EMRs truncate the code names, and if a provider is typing in search terms, they tend to pick the first code that comes up--which may not be correct, or specific enough. I audited an ortho clinic where the providers chose codes, and the doctors often picked "unspecified side" codes, even though they had documented the laterality. Why? Because it was the first one that would display.
 
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