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Help in understanding Dx coding

  1. #1
    Default Help in understanding Dx coding
    Medical Coding Books
    Would someone be willing to explain why in the billing context employees use Dx codes that don't reflect documentation, and then in other workplaces you hear coders say you can only code what is documented.....


    Why is this coders?

    an explaination other than needing to get paid would be great........... that is if their is another point to my above question.....

  2. #2
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    Quote Originally Posted by JoeytheShark View Post
    Would someone be willing to explain why in the billing context employees use Dx codes that don't reflect documentation, and then in other workplaces you hear coders say you can only code what is documented.....


    Why is this coders?

    an explaination other than needing to get paid would be great........... that is if their is another point to my above question.....
    You may want to talk to the "employee" who is using a dx that does not reflect the documentation, you may also want to find out how they are coming up with the dx they are using.

    I have found from personal experience that sometimes what the dr marks on the chargeslip is not exactly what is in their documentation but if you code from a superbill then you would code what the provider has written.

    I know some office who code only from the documentation but this would be the decision of the office as to what the billing/coding dept gets to do their charge entry.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
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    Quote Originally Posted by rthames052006 View Post
    You may want to talk to the "employee" who is using a dx that does not reflect the documentation, you may also want to find out how they are coming up with the dx they are using.

    I have found from personal experience that sometimes what the dr marks on the chargeslip is not exactly what is in their documentation but if you code from a superbill then you would code what the provider has written.

    I know some office who code only from the documentation but this would be the decision of the office as to what the billing/coding dept gets to do their charge entry.

    Thank you Ms. thames

  4. #4
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    I know in my office the charge entry people are entering directly from the charge slip and this is not always what is in the documentation. I audit a certain number of charts per M.D. and this is an ongoing training issure with them. Every month when I give them their "report cards" this is a big issue. (That and the fact that they list every dx the patient has ever had on the charge slip). We are transitioning to an EMR and hopefully they will start getting a little better.

    Doreen Clark, CPC

  5. #5
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    Quote Originally Posted by dclark7 View Post
    I know in my office the charge entry people are entering directly from the charge slip and this is not always what is in the documentation. I audit a certain number of charts per M.D. and this is an ongoing training issure with them. Every month when I give them their "report cards" this is a big issue. (That and the fact that they list every dx the patient has ever had on the charge slip). We are transitioning to an EMR and hopefully they will start getting a little better.

    Doreen Clark, CPC


    Thank you Ms. clark

  6. #6
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    Based on my personal experience it is generally a lack of education that allows this to go on.

    Occasionally you will have instances where the provider forgets to dictate information about a dx he put on a charge sheet. This is not the norm though.

    Unfortunately, more often than not it is to get paid. Very sad, and one the reasons we are under the microscope more so than most other industries.

    I have seen doctors use a different dx on the charge sheet because the patients insurance won't cover obesity, anxiety, or whatever. I have also seen billing staff get a rejection, find a covered dx and send it back in with out even checking the documentation. Same can be said for CPT codes and modifiers.

    It amazes me how many people in this industry don't even know what the initials OIG stand for, much less what the OIG does.

    Laura, CPC

  7. #7
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    Quote Originally Posted by katmryn78 View Post
    Based on my personal experience it is generally a lack of education that allows this to go on.

    Occasionally you will have instances where the provider forgets to dictate information about a dx he put on a charge sheet. This is not the norm though.

    Unfortunately, more often than not it is to get paid. Very sad, and one the reasons we are under the microscope more so than most other industries.

    I have seen doctors use a different dx on the charge sheet because the patients insurance won't cover obesity, anxiety, or whatever. I have also seen billing staff get a rejection, find a covered dx and send it back in with out even checking the documentation. Same can be said for CPT codes and modifiers.

    It amazes me how many people in this industry don't even know what the initials OIG stand for, much less what the OIG does.

    Laura, CPC

    Thank you Laura!

  8. Smile
    It has always been drilled in my head that if it is not documented, they didn't do it. I code for Physican portion of the ER and I get both the progress notes and the billing ticket. I have made it clear to the doctors that I don't care what they write on the billing ticket because I code from the progress notes. NOT IN THE PROGRESS NOTES, YOU DIDN'T DO IT. Internal audits may help to clear that before RAC .

  9. #9
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    Quote Originally Posted by freckles View Post
    It has always been drilled in my head that if it is not documented, they didn't do it. I code for Physican portion of the ER and I get both the progress notes and the billing ticket. I have made it clear to the doctors that I don't care what they write on the billing ticket because I code from the progress notes. NOT IN THE PROGRESS NOTES, YOU DIDN'T DO IT. Internal audits may help to clear that before RAC .
    Thank you freckles

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