Wiki Wound care profee - can't use the entire documented note to code

[mjstack]

Looking for clarification; We use Wound Expert for both profee and facility services. the nurses and the Dr enter everything in 1 note. As coder for profee, I code what services the doctor has performed (ie: e/m, debridement, etc); nurse procedures (bandages changes, unna boot, ect) are billed by facility coder. My question is, our auditors are telling me I can only use the 2 short free text sentences' to code anything since those are the only thing the doctor has entered. As example," Wound is doing better". Nurse is also acting as a scribe, the doctor is very old school and doesnt like to type. Meanwhile, the patient had documented in note, DM, HT, CDK, Stroke, Fell, NPU, (as example) but because the doctor only says "wound" I can only use Sxx.xxxD code. Has anybody else had this issue? VERY CONFUSED. been coding Wound Care for 6 years, thank you

 

[kdlberg]

If the nurse/scribe notes include what the doctor discussed with the patient and what the doctor did (as far as addressing the other problems), I don't see why you can't code for them. Scribe notes co-signed by the provider are treated as if the provider themselves did the documentation.

In office coding (which is what I do), under the 2021 E&M rules, we are only supposed to code what dx's have an assessment and plan for that visit date. So if all of those were in the patient history but there were only plans for the wound, CKD, and DM, we could only code those three things. If that's what the auditors are using as guidance, you may want to look at profee specific rules--like "can you code other conditions that affect patient treatment?"

 

[thomas7331]

I agree that if the nurse is acting as a scribe and the documentation clearly says so and is authenticated by the provider, then it should be appropriate use to that information for coding the professional services. But this is a difficult area as a nurse acting in a dual role like this can be a compliance concern and can also create confusion in the documentation as to what work was done by the nurses and what was the provider's work. The physician cannot simply sign off on the nurses' notes and claim that work for themselves - the documentation needs to clearly show who did what. If your auditors are not agreeing with what you as a coder are understanding from the documentation, then it's also likely that a payer auditor might also not be clear as to who did what and could cause a real problem down the road.

This is something your manager or your compliance department needs to be involved in to help bring to a resolution. It could be that your providers' and/or nurses' documentation process needs to be changed for clarification. You need someone on site who can take a close look at this documentation and bring your coding and auditing processes into alignment and make sure everyone has the same understanding and you're all doing this the right way.