Our providers select their own ICD10 codes in our EMR. Unfortunately, the EMR dx code descriptions are not always accurate to the true code definition in the manual. For example, our EMR may have the description of bilateral, but the code is right or left, not bilateral. Because the providers don't know the codes and are searching for the codes by terminology, they believe they have selected the correct code, which, unintentionally, results in a lot of coding errors. As certified coders we catch most of the errors before submitting the claims and as long as the documentation is specific, we will change or correct the diagnosis code in the claim/billing module, but not in the progress note. In this circumstance we do not typically notify the provider since the documentation supports the correction. If the documentation is not clear or specific, we will query the provider for the correct code and ask them to addend the note.
How does your office handle this type of situation? Do you as certified coders have the authority from your organization to correct diagnosis codes, and if so, do you notify the providers that you have done so and have them addend the note?
Thanks.
How does your office handle this type of situation? Do you as certified coders have the authority from your organization to correct diagnosis codes, and if so, do you notify the providers that you have done so and have them addend the note?
Thanks.