Wiki Who documents what and changing ICD-9 codes

[coder2533]

I am looking for some concrete information on a few topics. Links to the source would be great!
Which staff members can document which parts of the visit? I know this information, but I am looking for something in black and white from a reliable source.

Also, if the EHR software requires a provider to choose a diagnosis code, but they choose the incorrect one, can we change this on the claim form without the provider making the same changes to the actual record? We are still billing what he diagnosed, just using the proper code instead of the one he chose. Again, I am looking for something in black and white.

Thanks!!

 

[maureen1]

Compliance from Providers

I am in the same boat. I need concrete black and white evidence to present to our providers that we as coders have the right to override their diagnosis codes. Where can we get that information.

 

[MnTwins29]

There is no regulation or rule that states who may assign a code. This is driven by policies at each facility. The coding guidelines will state WHAT the code assigned is based upon, namely physician documentation. If your providers hire you as coders, they are showing that they value your knowledge, skills and input. The ICD-9 guidelines do state that coordination between the physician and the coder is essential to proper code assignment. You could show your providers these guidelines and stress that you are not there to argue or disagree with them - you are there to work with them to ensure the most accurate codes are assigned.

A good place to find which staff members can document certain information would be the 1995 or 1997 E/M documenation guidelines from CMS. Those state who can document parts of the history, such as ROS and PFSH. For diagnoses, it does have to be based on PHYSICIAN documentation - not nursing, lab or X-ray results, etc. Again, coding guidelines such as the ICD-9 guidelines can help here.