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EMR & Documentation

  1. Default EMR & Documentation
    Medical Coding Books
    When auditing a charge and the MD marks a diagnosis as primary in the EMR and upon review you find that it is incorrect, what is the proper way to addend before sending to the insurance company? Does the MD need to correct PRIMARY dx and list it as PRIMARY with another diagnosis they picked or can the coder correct it to another diagnosis based upon review of the records? It is my understanding that the primary dx picked needs to match the diagnosis on the charge. Is there is any reading material on this that would be helpful?

  2. #2
    Default
    Quote Originally Posted by TFISCHER22 View Post
    When auditing a charge and the MD marks a diagnosis as primary in the EMR and upon review you find that it is incorrect, what is the proper way to addend before sending to the insurance company? Does the MD need to correct PRIMARY dx and list it as PRIMARY with another diagnosis they picked or can the coder correct it to another diagnosis based upon review of the records? It is my understanding that the primary dx picked needs to match the diagnosis on the charge. Is there is any reading material on this that would be helpful?
    Good question - I'd like to know, as well. I believe that I was taught to assign the most appropriate code and FYI the MD. I've noticed our EMR is attaching some of the wrong ICD-9's for the physicians' intended selection. That may not be a standard procedure, though.

  3. #3
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    Columbia, MO
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    The first-listed dx on the clim must be appropriate for the documentation along with the guidelines. If the provider selects the wrong dx code or the wrong first-lisyed dx code, the code is not only allowed but should change this, as far as alterting the physician etc.. that is up to your office policy. However it is wrong for a coder to assign incorrect dx codes or incorrect order just because that is the one selected by the provider.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Default
    Even if through the documentation you see the diagnosis code should be something different than what the provider initially appended a coder should not make changes to the ICD-9 code (s) on the claim without appropriate physician direction. If you feel it needs to be changed, you would need the provider to make the changes.

    If the claim has already been filed, if it is a subsequent date when this is caught, or if it is inpatient or out patient will determine your approach and handling of the correction.

    A best practice would be to alert the physician of your findings, inpatient= through an appropriate query, outpatient, a flag, discussion, and apropriataly ammended PG note.

  5. #5
    Location
    Columbia, MO
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    12,843
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    I disagree... A coders job, their profession is to select the appropriate code based on the documentation and the coding guidlines. Physicians are not taught coding and many times make errors in code assignment. If you have a policy in your office that coder selections must be provider approved then that is your own internal policy. However a coder must be knowledgeable enough to assign the appropriate code and there is no law, regulation, or statute that states a provider must approve a coders selection. If a coder is assigning codes based on the documentation there should be no reason for correction after the fact. If a coder must have every selection approved by the physician before claim submission then the entire process becomes too slow, and If a coder only uses the codes selected by the physician witout benefit of the documentation, then they are not a coder, they are performing data entry.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    Quote Originally Posted by mitchellde View Post
    I disagree... A coders job, their profession is to select the appropriate code based on the documentation and the coding guidlines. Physicians are not taught coding and many times make errors in code assignment. If you have a policy in your office that coder selections must be provider approved then that is your own internal policy. However a coder must be knowledgeable enough to assign the appropriate code and there is no law, regulation, or statute that states a provider must approve a coders selection. If a coder is assigning codes based on the documentation there should be no reason for correction after the fact. If a coder must have every selection approved by the physician before claim submission then the entire process becomes too slow, and If a coder only uses the codes selected by the physician witout benefit of the documentation, then they are not a coder, they are performing data entry.
    Agreed 100% - Doctors aren't taught to code extensively in medical school. If our coders assigned the codes as the physicians enter them into our EHR, every claim we'd send would deny. They often assign signs and symptoms along with confirmed diagnoses, and there's no particular order to the code assignment, to correspond with the various procedures performed. Their job is to practice medicine, and ours is to convert their documented work into the right codes. You can always FYI the physician that you made the change, and why, and if there's a disagreement, you can change it at that time and send a corrected claim.

  7. #7
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    Lets revise this...If you are abstracting a record and your job is to append the codes from the beginning then it would be permissable to make a codee change with physician agreement. .

    There should be some process identifying what coders in a practice/facility are allowed to do within the medical record with and without physician acknowledgement. Remember the physician is signing off on the chart and is ultimately responsible for what goes out the door regardless of who made the change. Not all coders know more than all physicians and there are many cases where coders make mistakes as well. If fraud is suspected the physician is going to be penalized as their signature is on that record not the coder.

    If the physician appended the initial codes and you don't agree then I think a best practice would be to review the difference with the physician and have some sort of tracking mechanism for their acknowledgement and subsequent agreement for someone other than themselves to change codes.

    Nicole

  8. #8
    Location
    Columbia, MO
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    I understand what you are saying,... However a coder should be knowledgeable enough to assign correct codes without having to have it apporved by the physician. I agree the physician is responsible for the codes and can be penalized but this is true for the coder as well. A coder does not "know more than the physician", however they do know more about the codes and rules for coding. A physician should feel confident that the coder is doing their job correctly. What you are suggesting for a routine basis is time consuming and will continually have the providers second guesing why a coder was even hired. The best way we have to justify our profession is to acurately and confidently assign the codes based on the documentation. In this way you can never be guilty of fraud and the reimbursement will be the maximum it can be. The worst thing we can do is to be data entry clerks that just apply provider selected codes and let it go out the door. This causes numerous back end editing and resubmission which then results in non optimal reimbursement. Every time you must re look at a claim due to coding errors then it has cost you more in some cases that what the claim will ultimately pay.
    I understand what you are saying I just disagree that it is the best way.

    Debra A. Mitchell, MSPH, CPC-H

  9. Default Signed acknowledment and Agreement
    Read this posting and I am looking for a copy of a letter or form for this. In several previous practices there was a letter signed by every Provider (MD, PA, NP, Nurse) that would be documenting in the EHR and services would be billng out under their name.

    The letter was part of the Physician in-processing paperwork that had to be signed. The letter/form acknowledged that certified coders would review the documentation and coding could or would be changed based on their documentation. The signed letter was acknowledgement and agreement of this process.

    This allowed the claims to bill out coded correctly, eliminated the repetitive notices sent to the providers and trends would be discussed during scheduled education sessions.

    Does anyone have a letter or form of this type?
    Last edited by sbicknell; 05-11-2012 at 08:17 PM.

  10. Default
    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.
    Dee
    CPC, CPCO, CPMA, CPCD

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