Wiki Coding Workflow and Documentation

[KStaten]

Fellow Coders, I'm curious as to what the normal process is for other coders, in terms of how you are assigned reports to code... For instance, do they come directly to you once documentation has been completed or do you generally have to sort through lists to find ones that are complete and ready to code? I've heard of cases from both extremes and am wondering what the "norm" is.

My second question is, How often do you normally have to send documents back for clarification from providers on any given day?

Thanks

 

[csperoni]

I'm not sure there is a norm here. There are probably as many different workflow processes as there are different EHR systems.

For my staff, op notes are placed in a specific folder for coding. Office notes however, the staff must look at the list of patients each day and the completed/signed notes are indicated on that list. There are reports that can be run to ensure we didn't miss something before timely.

Clarification can be very dependent on the clinician. Personally, as the practice manager, I am also concerned about any discrepancy in documentation even if it doesn't affect/impact coding, so I probably send back more than my coders would. Op notes it's rare to send queries unless I have a new provider. Sometimes it's really just about understanding how they document something that I don't have the clinical knowledge about even if the documentation doesn't need any changes. Or clarifying a procedure I've never seen before.

Maybe 2-3 per month total for 3 physicians on op notes. Office notes however, it's more like 20-30 per month total across 4 clinicians and we are currently adjusting workflows to decrease that.

 

[amyjph]

Agreed. You'll find hundreds of different workflows (maybe more) depending on the practice, size, hospital vs. private practice, service line, etc. etc. etc.
Most have a work queue where the daily visits or schedule are available and go from there. In my experience the work queue was assigned to a coder and the coder retrieved their own op reports from the hospital or ASC for surgery. The office visits and office procedures lived in the EHR. Trauma required direct access to the hospital record. I am talking about an external non hospital owned practice here. Sorting through lists is really inefficient but sometimes it's unavoidable because you won't always know if you have to send something back or if it's actually "complete". It would be ideal if only complete and signed dictations "ready to code/bill" flowed to the coder queue.
Some offices have only edit coders where the practice management system runs it through the engine and you only get "rejected" or dirty claims to work.
Some providers code their own stuff ("scary") without a coder really seeing it unless it hits an edit.

Like Christine stated above, sending documentation back is going to depend on the provider, how well (or poorly) they document, the practice P&P and the experience and strength of the coder among other things.

There really is no black and white answer or standard just commonalities.