kimberagame
Contributor
Hello all,
With the reduction in provider documentation burden that has been implemented in recent years, I'm seeing some of our providers becoming much more vague on details in their office notes. Not documenting laterality has been a big problem. They say the details were documented previously in the chart, and they don't need to keep repeating them each time with these new rules. I understand and agree that this is the case for them, however, I've yet to see anything that has allowed coders in private practice settings to draw information from anywhere other than the note they are currently coding. I understand that hospital coders can draw info from anywhere in a patient's chart, but my schooling (about 6 years ago now) was for the clinical side, and we were taught everything had to come from the office visit note being coded. The only exception was if a previous note was referenced by date, we are allowed to draw info from that note as well. I learned this, and all the coders at the job I subsequently got also held this as law. My question for you is, has this changed? Or was this incorrect to start with? Any time I look into where coders can get info, sources say it can come from anywhere in the chart. But I'm concerned the source is talking about hospital coders, since I know that's the case for them. Can coders on the clinical side also take our info from anywhere in the note? Thanks for your help!
With the reduction in provider documentation burden that has been implemented in recent years, I'm seeing some of our providers becoming much more vague on details in their office notes. Not documenting laterality has been a big problem. They say the details were documented previously in the chart, and they don't need to keep repeating them each time with these new rules. I understand and agree that this is the case for them, however, I've yet to see anything that has allowed coders in private practice settings to draw information from anywhere other than the note they are currently coding. I understand that hospital coders can draw info from anywhere in a patient's chart, but my schooling (about 6 years ago now) was for the clinical side, and we were taught everything had to come from the office visit note being coded. The only exception was if a previous note was referenced by date, we are allowed to draw info from that note as well. I learned this, and all the coders at the job I subsequently got also held this as law. My question for you is, has this changed? Or was this incorrect to start with? Any time I look into where coders can get info, sources say it can come from anywhere in the chart. But I'm concerned the source is talking about hospital coders, since I know that's the case for them. Can coders on the clinical side also take our info from anywhere in the note? Thanks for your help!