Wiki Incorrect Gender in Dictation--Compliance Issue??


True Blue
Baton Rouge
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This question was recently posed to me by our Med Rec Supervisor, and I wanted to get some opinions here. Is there a compliance issue if the doctor misuses gender throughout dictation? For example, patient is female, "female" is checked off in EMR when the account is originally set up, but "he/his/him" is used for the entire office note. I don't remember ever coming across anything that states this is "wrong"...but it definitely makes the doctor--and our clinic--look bad!

Would appreciate any input/opinions/resources anyone may have.

well it depends I guess. We had this become an issue with a patient that was male but wanted to be referred to as female and respecting the wishes of the patient the provider did just that. Theproblem is this patient had breast cancer, and because the dictation was always she and her, the code used 174.9 for the breast cancer and no one ever questioned it, however when it was my turn and I got the chart, SHE had mets to HER prostate! THEN it became a big deal. The problem was in billing when the 174.9 was rejected for a gender edit, the billing changed the patient gender to female with a copy of the dictation and all was well. The wrong breast cancer code prompted by the incorrect gender reference in the medical chart upheld by the provider dictation and then confirmed by the patient when verbally queried by the payer, cause a bigger issue when it came to the mets diagnosis and everything needed to be reversed. It was a huge undertaking to fix. I know of no sources to help but just be certain the coder verifies the gender according to the chart and not the pronoun reference.