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Physician coding..

lopezk89

Networker
Messages
59
Location
Minnetonka, MN
Best answers
0
I HAVE A QUESTION THAT I FIND TO BE COMMON KNOWLEDGE BUT I DO NOT KNOW THE ANSWER TO THE QUESTION.... I SPOKE TO ONE OF MY PROVIDERS THE OTHER DAY AND I WANT TO KNOW THE LIMITATIONS TO CODING WHAT CAN I CODE OFF AN OFFICE NOTE DO I NEED TO HAVE THEM CODE IT AND CORRECT IT OUR CAN I CODE OFF THERE OFFICE NOTE. WHAT AM I BY LAW ALLOWED TO DO ..... AND IS IT ILLEGAL FOR ME TO CODE THEIR OFFICE NOTE DO THEY HAVE TO PHYSICALLY CODE IT.....:confused::confused::confused::confused::eek:
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
You may code from documentation as long as you are the employed agent of the practice so if you are the office coder or a billing service providing coding you may code from the note even if your codes do not match theirs, the claim needs to reflect the documentation.
 

lopezk89

Networker
Messages
59
Location
Minnetonka, MN
Best answers
0
Cool

SO WHAT IF IN THE CASE THEY DO NOT CODE ANYTHING AN GIVE ME THE OFFICE NOTE TO CODE FROM..... HYPOTHETICALLY AND WOULD THAT BE ILLEGAL.... I JUST WANT TO KNOW MY FACTS.:confused::confused::confused:
 

JMeggett

Guru
Messages
226
Location
Spokane Valley, WA
Best answers
0
I HAVE A QUESTION THAT I FIND TO BE COMMON KNOWLEDGE BUT I DO NOT KNOW THE ANSWER TO THE QUESTION.... I SPOKE TO ONE OF MY PROVIDERS THE OTHER DAY AND I WANT TO KNOW THE LIMITATIONS TO CODING WHAT CAN I CODE OFF AN OFFICE NOTE DO I NEED TO HAVE THEM CODE IT AND CORRECT IT OUR CAN I CODE OFF THERE OFFICE NOTE. WHAT AM I BY LAW ALLOWED TO DO ..... AND IS IT ILLEGAL FOR ME TO CODE THEIR OFFICE NOTE DO THEY HAVE TO PHYSICALLY CODE IT.....:confused::confused::confused::confused::eek:
Different Providers have different comfort levels when it comes to trusting their coders and there are no rules or laws that say how much or how little you're allowed to code or change a Provider's codes. That is strictly determined by your employer. Alot of Providers want their Coders to do all of their coding for them. In our office, for surgery, we have some Providers that want to code their own and we have to explain to them "why" when we change a code or when a code is "bundled". And then other Providers don't care and want us to do it all. For the office visits ALL of our Providers are required to choose their own E&M level and we then review them and have the written approval to change those levels if needed. For instance, it's too mundane for them to keep track of which insurance carriers will pay on a Consult code and which ones won't...so they always choose a Consult when applicable and then we change it to a New Patient visit or Established Visit on those that won't accept Consult codes. Or they bill out an office visit when it's really a Pre-Op visit and not billable...stuff like that where they would need to be Billers to know what to code sometimes! It's all a matter of comfort/trust level they have with you and what policy they have in place. If there is no policy in place, talk with them and see in what situations they WOULD be comfortable with you changing a code for them. Maybe keep a spreadsheet that your Provider can view of any changes you make...so he feels he has some control and can squack if necessary. Good luck!
Jenna
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
SO WHAT IF IN THE CASE THEY DO NOT CODE ANYTHING AN GIVE ME THE OFFICE NOTE TO CODE FROM..... HYPOTHETICALLY AND WOULD THAT BE ILLEGAL.... I JUST WANT TO KNOW MY FACTS.:confused::confused::confused:
It most definitely is NOT illegal. If fact it is performing the job of the coder. You are suppose to code from the note. I prefer personally that the comes to me without having been coded by the provider.
 

lopezk89

Networker
Messages
59
Location
Minnetonka, MN
Best answers
0
Sweet Deal

So just to make sure do they have to pick the level of the service..... So i know these are stupid questions....;);)
 

mitchellde

True Blue
Messages
13,538
Location
Columbia, MO
Best answers
2
No they do not, you should be just a capable if not more so to pick the level of service, procedure codes and all dx codes as long as it is documented and you follow all official guidelines.
 

viola25

New
Messages
4
Location
Indian Trail, NC
Best answers
0
As long as the documentation supports your diagnoses can code off of their office note. wehre else are you to find the documentations if not based on their notes. Of course it will be illiglal if you do not follow the official rules and guidelines of coding.
 
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