Revenue Cycle Insider
General Coding:
Know Limitations of Coder Privileges
Published on Mon Oct 28, 2024
Question: One of the patient records I’m reviewing shows a pretty big discrepancy between the template portion of the symptoms and diagnosis compared to the written note portion, which I know this provider records with dictation. I’m sure they just checked the wrong box on the template portion. Can I go ahead and adjust the record so it’s consistent, with the template now matching the accurate, dictated notes? California Subscriber Answer: As a coder, you’ve probably seen a lot of patient records and can see when something might be amiss. However, documentation — including notes about an encounter — should be adjusted only by providers, and any adjustments made should follow the proper procedures for addendums, including signatures acknowledging and dating any changes. This is a situation in which you should query the physician about the inaccuracies you noticed so the clinician who provided the service — and knows exactly what happened during the encounter — can review and revise the record accordingly. Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
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