EM Coding Alert

Question: Who is responsible for the final diagnosis used for an office/ outpatient evaluation and management (E/M) visit? If a coder is reviewing documentation prior to the charge being sent and notices a diagnosis error, would/should/could the

coder update the diagnosis, or is this the responsibility of the provider?

AAPC Forum Participant

Answer: While the provider is responsible for all claims submitted under their name, the answer to this question varies based on your employer. Some providers refuse to allow anyone to change their codes, while some have a query system where the diagnosis code must be sent back before changes can be made to confirm the correct code choice. But most employers allow coders to change a code picked by a provider when the documentation supports a more appropriate code.

Ultimately, the responsibility for assigning the correct diagnosis code is upon the provider. However, code assignment within the billing system and/or on the claim may be left up to the coder providing the claim accurately aligns with the documentation in the patient’s medical record. In such situations, just make sure you are not assuming or inferring information from the documentation, and that the documentation supports a different, more accurate code. You must never assign a code arbitrarily or change the documentation to fit a code.