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ICD-9 codes in EMR

  1. #1
    Location
    north seattle wa
    Posts
    103
    Default ICD-9 codes in EMR
    Medical Coding Books
    I need something in black and white that states that ICD-9 codes in Medical records must be complete. I have an EMR system that lets the phyisians document unspecific verbage and codes. Example: 493.9 for asthma or 401 hypertension essential.
    Some here tell me that the HTN can be coded with the unspecified dx.
    My point is that if you are giong to assign an ICD-9 code that is it has to be complete otherwise it is invalid (ICD-9 guideline).
    Their point is that as a coder I can code from the documentation and use unspecified diagnosis.
    Any thoughts or back up would be appreciated!

    Wendy

  2. #2
    Default
    If your EMR is linked to your billing software then you must have the most specific ICD-9-CM codes so they will appear correctly on the claim. Our billing software interfaces with the EMR and the codes have to be specific to correctly appear on the claim.

  3. #3
    Location
    north seattle wa
    Posts
    103
    Default
    That is the problem. We don't bill from our EMR because we are rural health. The physicians fill out an encounter form and it is fed into codescan, but the girls have been adding the 4th or 5th unspecified digit before they bill it out.
    So they see this as a billing issue and not a documentation issue.

    The audit position is new here so I am discussing this with the physicians and the EMR people- this is why I need the back up that it has to be a complete dx if you are going to have it in the note. Unfortunately we cannot supress the code and just use the verbage, I already checked. That would have been too easy!!

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
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    We have a very similar issue with our EMR, and we do not bill from it. The providers get incomplete codes from the EMR and write them on the charge sheets. Since the codes cannot be entered into the billing system unless they are coded out to the furthest specificity, the charge sheets are returned to the providers to determine the fourth and fifth digits. My opinion is that there is a BOOK published every year with all the codes in it - called the ICD-9...and that should be used to determine diagnosis coding. Our EMR simply does not have the capability to code to the highest specificity. The other issue is, does this make the EMR note erroneous if the diagnosis code is not "complete"? I for one, would love to hide the codes!
    Lisa

  5. #5
    Location
    north seattle wa
    Posts
    103
    Default
    Our current EMR can take it to the highest level. Our problem is that the previous version did not have that capability so rather than taking the time to open all the "folders" to get to that highest level of code, my docs are either only going part way or pulling the condition from history into the assessment which gives them the code from the previous version. I also think that this would be erroneous documentation but I can't find anything in black and white to support it since it isn't being billed that way and we can use the whole note when we code.
    I sent a list of complete ICD-9 codes for their top 100 most used diagnosis to each doctor to help them update their diagnosis list. Hopefully it will help for future documentation. My concern is that with these RAC audits about to roll out nationwide, how are these auditors going to look at these codes? Are they going to see and incomplete dx code on a record and say it is invalid? That is the million dollar question.

  6. #6
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I'm curious as to what EMR software people are using...if anyone wants to share. I am not in IT, so I don't have much to do with the EMR other than trying to get valid ICD-9 codes out of it. We have NextGen.

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