Wiki CPT and ICD10 changes

[dgarrett10]

Can only a CPC audit a chart and make changes to the providers does after the chart is locked on the backend of the claim and not tell the provider and bill the changes.

 

[mnuhfer04]

Can only a CPC audit a chart and make changes to the providers does after the chart is locked on the backend of the claim and not tell the provider and bill the changes.

My providers allow me to change the level of the visit, they never argue with me about that. But anything else, I always ask first. What other sort of changes do you mean?

 

[csperoni]

If you question is whether or not a CPC is qualified to make changes to the coding portion, my answer is "Of course!" That is exactly what CPCs are trained for - to take the words and documentation and translate them into CPT, ICD10, and HCPCS codes using coding guidelines.
Whether or not this is what a specific employer allows a CPC to do and whether or not the provider is informed is a policy decision of the employer regarding the scope of work they are hiring a coder to do.
If the providers are expected to code, it makes sense to inform them about errors they are making. Sure, a typo is not really an educational opportunity. But a provider continually coding ICD10 excludes1 diagnoses will never know it's incorrect if no one ever educates them about their specific errors.
Now, regarding a chart being "locked", to me, that means the actual medical record. The codes are not part of the medical record, although most EHRs include this information.
Example: Provider documents in words that patient has moderate cervical dysplasia, but selects N87.9 (cervical dysplasia, unspecified), a coder is trained to translate the words of moderate cervical dysplasia into N87.1.
Example 2: Provider documents they performed a colposcopy of the cervix and upper vagina without biopsy, but selects 57455 colposcopy of the cervix and upper vagina with biopsy, a coder is trained to correct that to 57452.
Example 3: Provider documents a colposcopy with biopsy, but is not clear whether they examined and biopsied the vulva, vagina or cervix, regardless of provider's code selection, the provider should be queried for an amendment to the records. Once the records reflect the location examined and biopsied, a coder can correct (if needed) the provider's selection.
There are employers that do not expect nor want their coders to do this, even if certified. There are employers that expect their coders to do this even if not certified. There are no legal requirements about whether a coder can do this, nor whether or not they must be certified. That is at the employer's discretion.
I will note that ultimately, it is the provider's responsibility to ensure coding submitted under their name is correct, so should be informed about any significant or repeated changes.

 

[sls314]

If you question is whether or not a CPC is qualified to make changes to the coding portion, my answer is "Of course!" That is exactly what CPCs are trained for - to take the words and documentation and translate them into CPT, ICD10, and HCPCS codes using coding guidelines.
Whether or not this is what a specific employer allows a CPC to do and whether or not the provider is informed is a policy decision of the employer regarding the scope of work they are hiring a coder to do.
If the providers are expected to code, it makes sense to inform them about errors they are making. Sure, a typo is not really an educational opportunity. But a provider continually coding ICD10 excludes1 diagnoses will never know it's incorrect if no one ever educates them about their specific errors.
Now, regarding a chart being "locked", to me, that means the actual medical record. The codes are not part of the medical record, although most EHRs include this information.
Example: Provider documents in words that patient has moderate cervical dysplasia, but selects N87.9 (cervical dysplasia, unspecified), a coder is trained to translate the words of moderate cervical dysplasia into N87.1.
Example 2: Provider documents they performed a colposcopy of the cervix and upper vagina without biopsy, but selects 57455 colposcopy of the cervix and upper vagina with biopsy, a coder is trained to correct that to 57452.
Example 3: Provider documents a colposcopy with biopsy, but is not clear whether they examined and biopsied the vulva, vagina or cervix, regardless of provider's code selection, the provider should be queried for an amendment to the records. Once the records reflect the location examined and biopsied, a coder can correct (if needed) the provider's selection.
There are employers that do not expect nor want their coders to do this, even if certified. There are employers that expect their coders to do this even if not certified. There are no legal requirements about whether a coder can do this, nor whether or not they must be certified. That is at the employer's discretion.
I will note that ultimately, it is the provider's responsibility to ensure coding submitted under their name is correct, so should be informed about any significant or repeated changes.

I agree with Christine.

Coders are trained to translate the words and documentation in a chart into the appropriate codes. I review all of the codes on my physicians' encounters before the claims are billed, and I update the claims as needed and as supported by the verbiage in the documentation. I don't pay much attention to any codes assigned by the EMR - I review the actual words documented in the note.

Are you talking about the medical record or the claims? The coder doesn't change the visit note itself, even though many EMRs put a code along with the verbiage on the note.

Codes billed on claims should be supported by documentation and follow guidelines. That's absolutely within the scope of a coder's training and role.

Different employers may have internal policies on how that process will work and what communication should be given to the provider.

 

[amyjph]

As everyone is stating, it depends on what you mean when you say "audit a chart and make changes". Can you be more specific?

 

[Cls1530]

If my providers have given me permission to audit and change a level of service based off that or to add a diagnosis code to the charge when it is supported in the note, I would do that. However, I would still convey the information to the provider especially for a level of service change as they are the ones who are responsible for that on the legal side (for the most part). However, I would never change anything that is not supported by documentation and if asked to do so, would request the information be added or I would not do it.