Need advice. Our pediatric office uses an EHR that does code the visits. When reviewing the claims, if there are any corrections I need, such as a change to a diagnosis code like changing V20.2 to V70.0, I ask the provider to make the correction to the chart note also. I feel it is wrong to change the diagnosis in the claim, but not in the chart note even if the note does support the correct code, the incorrect code is still there. Am I wrong?
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Wiki Coding question
- Thread starter jweigel
- Start date
mitchellde
True Blue
The code numbers do not need to match. The narrative in the note must match the code on the claim. Since providers are not coders, and the EHR is not a coder, the codes in the record are often incorrect. The code number is truely not suppose to be in the medical record note and is definitely not a requirement. When I audit records, I pay no attention to the codes in the note. Only the narrative and the codes on the claim.
thomas7331
Guest
I agree with Debra, but I can relate - it does put the coder in the difficult position of contradicting what the physician has put in the document and signed. Codes are supposed to be a translation of documentation, not a substitute for it!