Gastroenterology Coding Alert

Physicians must take care that the record actually matches what they did. If you use a templated electronic medical record or a transcriptionist to save time, watch out, or you may end up losing the time you saved and then some when your coder has to come back to ask what really happened, or when a payer rejects a claim. "Make sure that you're reviewing the documentation from time to time that is transcribed," Jill M. Young, CPC-ED, CPC-IM, tells physicians. Don't expect coders to read your mind. "If you don't have a complete record, if the diagnosis isn't given or easily inferred (in the endoscopy note), you can't extrapolate that out." "If the provider's schedule starts to get rushed, they may be distracted and not pay close enough attention to the details that need to be changed in order to accurately report what they did," says Tina Smith, CPC, [...]