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EMR & Documentation

  1. #11
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    Quote Originally Posted by DeeCPC View Post
    The medical record is a legal document. You must be the author of the record in order to change the record. You must have permission to change the codes.
    The coder is not amending the medical record, the coder is assigning the codes for the claim. The code should not even be in the actual medical document, if they are then that is because you have allowed your EMR to work that way. However as long as the codes on the claim match the physicians narrative documentation it does not matter that they do not match his/her particular code selection. If I could have have a voice loud enough and strong enough I would advocate that providers NEVER select the codes, it is just not time well spent on their part. Coders should be trained and knowledgeable enough to be confident in the code selection based on the medical record. The job of the coder is after all to code not to data enter codes that may or may not be correct.
    However back to your statement, the coder is not changing the medical record in any way. The is however creating another legal document... the claim which is in effect an attestation to the fact that the medical document will support all the information submitted.

    Debra A. Mitchell, MSPH, CPC-H

  2. Default
    I think we agree. Doctors should not be coders-they do not want to code.

    My point is if the provider is putting a code anywhere in the medical record then they need to agree to changing those codes.

    Many EMRs record the provider's assignment of CPT and ICD-9 codes directly into the notes. Not ideal but I do not create the systems.
    Dee
    CPC, CPCO, CPMA, CPCD

  3. Default
    Quote Originally Posted by DeeCPC View Post
    I think we agree. Doctors should not be coders-they do not want to code.

    My point is if the provider is putting a code anywhere in the medical record then they need to agree to changing those codes.

    Many EMRs record the provider's assignment of CPT and ICD-9 codes directly into the notes. Not ideal but I do not create the systems.
    In my practice, simply choosing a code is not considered documentation that the service was performed. There must be actual documentation to back it up. Our job as professional coders is to educate the physicians to document appropriately.
    And i don't care what you are told by your employer, if you touched the claim before it went out the door, you could be considered legally responsible for it. Check out this article before you change another code! http://news.aapc.com/index.php/2007/...ity-of-coders/

    Happy and safe coding, everyone!

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