Gastroenterology Coding Alert

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, CPC-H, CPC-I, CGCS, CHCA.

"The biggest problem we had with endoscopy reports was simply the lack of detail needed to code accurately and without question," says Smith, who has a background as a GI coder.

Often, it's just a matter of the provider's unfamiliarity with coding.

"They don't know what needs to be in the report," she says. "Providing the detail needed saves time not only for the coder, but for the physician. The coder will not have to send the report back to the physician to clarify what was done."

Gastroenterologists "would be well advised to pay attention to the questions of their coders and then be sure to include the information in their future reports," Smith says.