# EMR & Documentation



## TFISCHER22 (Mar 19, 2011)

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?


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## btadlock1 (Mar 19, 2011)

TFISCHER22 said:


> 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.


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## mitchellde (Mar 20, 2011)

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.


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## martinni1974 (Mar 20, 2011)

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.


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## mitchellde (Mar 20, 2011)

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.


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## btadlock1 (Mar 21, 2011)

mitchellde said:


> 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.


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## martinni1974 (Mar 22, 2011)

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


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## mitchellde (Mar 22, 2011)

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.


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## sbicknell (May 11, 2012)

*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?


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## DeeCPC (Jun 18, 2012)

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.


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## mitchellde (Jun 18, 2012)

DeeCPC said:


> 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.


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## DeeCPC (Jun 19, 2012)

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.


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## janellefricks (Jul 25, 2013)

DeeCPC said:


> 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/2007/12/criminal-and-civil-liability-of-coders/

Happy and safe coding, everyone!


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