clynntarpley
New
Our software requires that the provider close out their note with a charge capture (selecting a diagnosis and the proper code that goes along with it).
Which is pretty dumb, since the providers are providers and not medical billers/coders.
In every note, below the charge capture, is a 'disclaimer' that reads:
**Please note: ICD descriptions below are intended for billing purposes only and may not represent clinical diagnoses**
So the problem we run into, is - the provider is unable to close out their note without selecting something. When we go to create the
invoices through the system, it automatically pulls their cpts/ICDs from the note to the invoice. The providers, again, are not coders, and browse/select
a diagnosis code that's usually just a ballpark figure, if you will, for what their actual diagnosis is, so they can close out the note and move on to the next.
Once the invoice is created, I go from there and delete the dx codes and replace them with the more appropriate one.
So my question is, if/when one of our payers requests documentation for a claim, does anybody happen to know what effect those diagnosis codes in the actual note have, if any? Our billing manager, understandably so, believes that the notes should be sent back to the provider to have the correct code addendum'ed to the note. But that would be EVERY note! We'd never get anything billed! And it's stupid when they've already documented the encounter, which is their job, and the code selection/whatnot is ours. And then, there's the 'disclaimer,' that states that the ICD descriptions are intended for billing/don't represent clinical diagnoses' (then why the HECK is it a 'requirement' of the note ANYWAY?!)
Any light or rhyme/reason for all this that anyone could shed on this very frustrating topic for us would be so appreciated... Anything besides 'get a new EHR system...'
Which is pretty dumb, since the providers are providers and not medical billers/coders.
In every note, below the charge capture, is a 'disclaimer' that reads:
**Please note: ICD descriptions below are intended for billing purposes only and may not represent clinical diagnoses**
So the problem we run into, is - the provider is unable to close out their note without selecting something. When we go to create the
invoices through the system, it automatically pulls their cpts/ICDs from the note to the invoice. The providers, again, are not coders, and browse/select
a diagnosis code that's usually just a ballpark figure, if you will, for what their actual diagnosis is, so they can close out the note and move on to the next.
Once the invoice is created, I go from there and delete the dx codes and replace them with the more appropriate one.
So my question is, if/when one of our payers requests documentation for a claim, does anybody happen to know what effect those diagnosis codes in the actual note have, if any? Our billing manager, understandably so, believes that the notes should be sent back to the provider to have the correct code addendum'ed to the note. But that would be EVERY note! We'd never get anything billed! And it's stupid when they've already documented the encounter, which is their job, and the code selection/whatnot is ours. And then, there's the 'disclaimer,' that states that the ICD descriptions are intended for billing/don't represent clinical diagnoses' (then why the HECK is it a 'requirement' of the note ANYWAY?!)
Any light or rhyme/reason for all this that anyone could shed on this very frustrating topic for us would be so appreciated... Anything besides 'get a new EHR system...'
