Wiki Incorrect ICD 9 codes in progress notes

[akbiller]

Our software (eclinical works) has the diagnoses codes attached to the physician assessments. The physician's are having a hard time finding the correct codes since they can only search from a huge list built in and can see only a small window at a time. Physician's are not trained in coding and do not understand coding regulations very well. The doctor's are very busy and do not have the time it takes to search all possible codes. Also the codes are entered in the software by the vendor and the descriptions do not always make sense or match the code book. Before we received our software additional offices were allowed to change the descriptions of the codes to suite what they wanted them to say as well. The descriptions are not entered in a consitent manner either. Sometimes you may have to search for pain knee or sometimes the other way around such as back pain. Because it can take so long and is quite cumbersome for the doctor to search for the appropriate code (as well as not fully understanding coding) the doctor's pick the first code that appears in the very small window that comes close to what they are looking for or seems to be correct to them. This is resulting in incorrect codes constantly. Almost every progress note. Is there any solution to this? The codes in the claims get corrected but who should correct the codes in the progress note? For instance doctor chose code for bursitis but should be shoulder bursitis. The claims and progress notes are rarely matching. Is the doctor the only one who can correct the progress note? Does anyone else have the same problem? Any help or advice is greatly appreciated.

 

[mitchellde]

This is something I fought hard with E clinical works and the trainers. They tell the docs that they can customize the ICD descriptors to say anything they want and consequently there is no integrity in the data base. you will have a single code that has many different descriptors in your system and maybe none will match the book. The progress notes should not contain the codes at all. this is something else I find wrong with many EHR systems, but you can have that stopped. The vendor can fix that for you and have the codes stop populating to the progress notes. We even had the system fixed to allow the doctors to not pick the codes at all, they were allowed to pend it without the codes and the coder could select the codes. We found this was the best solution for everyone.

 

[Skenyon]

Choosing ICD codes in the EMR

I think that all "certified" EMR systems, should use the same code data bases. I think something like en-coder pro would work nicely. Presently, our providers are chosing their codes as well, and it's unbelievable what they come up with! We are constantly adding addendums to the record with corrected codes.

I am especially concerned, when ICD-10 comes along. No matter how much I stress how absolutely different the coding will be, they seem to think it won't be a problem, because the EMR will have the list of codes to choose from (easy as that!).

NOT looking forward to 2013!

 

[ANDREAHSANCHEZ]

I work at a billing co. and we bill for several facility and non-facilities and this is a constant struggle. Some of the ways we have come up with to try and get this resolved is to create a spread sheet with any questions or charts that need to be reveiwed before they can be billed stating the problem(s). It makes it a little easier so when the doctor has time they can review and make corrections to everything all at once and not one here or there. Another system that we use for our urgent cares is a new program PV, practice vilocity although it is only designed for urgent cares specifically it is fabulous program I would highly recomend to anyone. Of course the doctor must utilize but if done correctly it is so much nicer than any progam I have seen or used. I know it can be hard to get a responce from the doctor many times but I am sure they are the only ones who can change the info. so we have to find our own system or way around. Good luck.