# Help in understanding Dx coding



## 007CPC (Jun 17, 2009)

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.....


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## rthames052006 (Jun 17, 2009)

JoeytheShark said:


> 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?
> ...



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.


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## 007CPC (Jun 17, 2009)

rthames052006 said:


> 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


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## dclark7 (Jun 18, 2009)

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


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## 007CPC (Jun 18, 2009)

dclark7 said:


> 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


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## LLovett (Jun 18, 2009)

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


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## 007CPC (Jun 18, 2009)

katmryn78 said:


> 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.
> 
> ...




Thank you Laura!


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## codingranny (Jun 18, 2009)

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 .


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## 007CPC (Jun 18, 2009)

freckles said:


> 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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