vender vs medicare

VRcoder29

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I have posted a thread about this before. It has come up at my employement again. We are a small hospital with about 50 providers with different specialties. I work for the physician side of the hospital. About a year ago we went to a new computer system, and in about 2 months they are incrementing the 2nd part of the new system.
What this consist of is the Dr and nurses choosing the office level and diagnosis codes for this patient through a "drop list" and it will go on the office visit. After that, the office visit goes to us to read the note, verify they used all the correct CPT codes ( E/M new vs Established, captured all procedures, etc... and the correct diagnosis codes) the good news is, if the DX code is wrong we can change it. Also is the CPT code is incorrect we can change that as well, we just have to re-educate the physician.. . ( because we supposively have all the time in the world, especially since there is only 6 coders and 50 plus Drs)
Here is the part that really confuses me. I am not sure if it is the vendor problem or if this an actual medicare rule. Whatever the DR/Nurse picks...that is what stays on the record . Therefore, if they pick something completely off the wall... it will go on that patients documentation
...**example**(male comes in for a prostate exam...lets say my nurse chooses V76.12 ...we know that is NOT correct. I would change it to the correct ICD9 code and send it to be filed to the insurance. However, when you look at that patient's progress note....at the bottom of the documentation the code V76.12 will still be on there.)

Now this is the vendor telling us the ICD9 code the nurse/Dr picks will stay on the patient's documentation.

We as coders told the people in charge.. " That is not going to work. As a patient you wouldn't want the wrong information stuck on your medical record."
The vendor says "this doesn't matter as long as we correct the codes.What we correct will go out on the claim, however it will not go on the patients medical record. This is what medicare wants because medicare wants proof the provider is choosing their own E/M levels and know how to code."
When did this rule go into effect? I haven't seen anything about medicare requiring this from a provider. I can understand them wanting the provider to choose their own E/M level but to choose the wrong DX could be permantly damaging to the patient.

Any insite on this?
 

mitchellde

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This rule did not go into effect because it in fact does not exist. The vendor has created a product, that is unfortunately like many other products and they do not want to change it. Medicare has no rule that the provider must be the one to chose the codes. If you can tell the vendor to turn off the coding function then the providers and nurses will not long be required to be the ones to append the codes and the will not append to the medical record. There is in fact an AHA coding clinic in 2012 although I do not recall which quarter (1st?) that states the numeric codes should not be in the medical record document.
 

VRcoder29

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awesome

I need to see if I can find that article. If you find it or remember it...let me know. Also I could tell all the people in charge that info and they won't listen to me... but i want to know for my own sake
 

mitchellde

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It is a coding clinic which must be purchased. I know the exact issue was referenced in a previous post somewhere you could do a forum word search for coding clinic that might find it.
 
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