Wiki Changing Diagnoses

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herediacarolina

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Hello, I'm a recently certified CPC and I'm looking through the forums but I can't find recent information regarding diagnoses changes.
My question is: Can a CPC change the diagnosis assigned by a physician if is found to be incorrect based on the documentation? Our clinic sees a lot this situation where the physicians select incorrect coding and we are filling out a form to get back to them with questions and suggestions regarding appropriate coding. Can I as CPC correct the coding without having to ask them every time?
Thank you very much.
 
You will get two different answers to your question. One group will say, "NO!! We never change the code without provider approval," and the other group will say, "YES!! It is our job and duty to change the code, provided we have proper documentation in the note."

My doctor is notorious for clicking the Dx from his problem list but forgetting to actually say in plain language what the Dx is on his assessment line. Often, I can find the justification in his excellent subjective or exam paragraphs, but other times, I have to query him and even have him make an addendum to his EHR note.

Take it on a case-by-case basis and don't be afraid to let your physicians know that you need more documentation. For my part, I'm in the group that will change a code if I find the evidence to change it, but I'm also aware that I had better be able to back it up if audited. You will find your balance.
 
Thank you so much for your posting erjones147. I just wish there was something in writting to go by. I haven't been able to find anything in the guidelines or elsewhere that would state it's ok to make changes when the documentation suports it or something that states that it's not ok. However, I agree with you that a change should be allowed as long as there is evidence in the documentation.
 
herediacarolina said:
Thank you so much for your posting erjones147. I just wish there was something in writting to go by. I haven't been able to find anything in the guidelines or elsewhere that would state it's ok to make changes when the documentation suports it or something that states that it's not ok. However, I agree with you that a change should be allowed as long as there is evidence in the documentation.
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I agree with erjones, and I think the true answer will have a lot to do with each different clinic's individual policy. I am allowed to change anything I see that is incorrect, without having to get provider approval. I definitely agree that that makes great educational opportunities for providers. Overall, my opinion is that coders should be able to make changes. However, I don't remember ever coming across any legal or official guidance stating that.

Hope this helps!
 
I would recommend meeting with your providers to ask for guidance and have a clear cut written policy or protocol to follow. The doctor is ultimately responsible for whatever is in the documentation so it's his/her reputation/responsibility to be correct in the final diagnosis. And, subjective complaints by the patient are not evidence based medicine, ie. "my right calf is numb" does not mean a diagnosis of lumbar radiculopathy without documented clinical evidence of radiculopathy.
 
Yes I would definitely meet with your providers to see what they would like done. It also would depend on the situation. For instance if I see they selected unspecified joint pain but it clearly says knee on the chart I will change it to the right one but if its something where the chart my say one thing and the diagnosis is something completely different and your not even sure why they selected the code I would want to bring it to there attention to figure out why they selected that code. Like Marcus said the doctor is ultimately responsible for whatever is in the documentation.
 
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