warrenfamily103@gmail.com
Networker
Hello everyone,
I am needing help with something... one of my providers stated that they can document something on the progress note but not code it out. Is this accurate? We are on paper charts still and on our encounter form they either circle or write in diagnoses. I then compare to the chart and code out correctly. If something isn't on the encounter, but is on the progress note, how should that be handled? When auditors review the records, if they see missed coding opportunities, will that reflect negatively on me as a coder, looking like I missed something? I don't know exactly how to approach this. Any guidance would be greatly appreciated.
I am needing help with something... one of my providers stated that they can document something on the progress note but not code it out. Is this accurate? We are on paper charts still and on our encounter form they either circle or write in diagnoses. I then compare to the chart and code out correctly. If something isn't on the encounter, but is on the progress note, how should that be handled? When auditors review the records, if they see missed coding opportunities, will that reflect negatively on me as a coder, looking like I missed something? I don't know exactly how to approach this. Any guidance would be greatly appreciated.