Tactics to Reduce Retrospective Coding Errors
Published on Sun Feb 01, 1998
Theoretically, all coding is supposed to be done by the person treating the child. The diagnosis and procedure codes should be done by the person providing the care, explains Allen D. Schwartz, MD, FAAP, a coding trainer for the AAP. Nobody else knows the work that was done, says Schwartz, who is with FPA Pediatric HealthCare Associates, a 3-physician practice in San Diego, CA.
But in reality, much of the coding is done by office staff -- especially when it comes to patients who are seen in the hospital. Here are some tips for coding retrospectively, something you may not want to do, but when necessary can be done smoothly -- if its done right.
1. Rely on pediatricians notes. I start with the history and physical that should be in the chart, says Wanda Reinecke, office manager for Victoria Pediatrics, Victoria, TX. If any of the doctors see a patient, there has to be a history and physical, she tells us. And if hes put in the details of the symptoms, that makes coding a lot easier. For hospitalized patients, there will also be an admitting summary and a discharge summary, which can be helpful.
2. Get hospital information. If a patient is hospitalized -- and that is where many of the coding gaps are -- you can get some good information from the hospital, Reinecke advises. However, one drawback of this is that the information doesnt come from the hospital until two weeks after discharge, and Reinecke likes to get all the codes recorded and submitted before that.
(Tip: If you do use hospital documentation for information purposes, remember that hospitals use rule-out codes, signs and symptoms for diagnosis codes, and follow with the observation for suspected condition codes. You will have to interpret these codes and apply the appropriate CPT and ICD-9 codes for your office billing in order to be reimbursed.)
3. Dont wait too long to code. If you need to get more information from the pediatrician to fill in the codes, you would be better off getting it done as soon as possible after the patient is seen. Reinecke tries to code all procedures and visits within two days of the date of service. Marilyn L. Schmidt, office manager for Southwest Pediatrics, Palos Park, IL, gets all the codes down within a week of the date of service. If you wait too long, the pediatrician may not recall the details of the service.
4. Talk to the pediatrician. The chart should be your first point of reference when coding. But if you have questions [...]
