akbiller
Contributor
Our software (eclinical works) has the diagnoses codes attached to the physician assessments. The physician's are having a hard time finding the correct codes since they can only search from a huge list built in and can see only a small window at a time. Physician's are not trained in coding and do not understand coding regulations very well. The doctor's are very busy and do not have the time it takes to search all possible codes. Also the codes are entered in the software by the vendor and the descriptions do not always make sense or match the code book. Before we received our software additional offices were allowed to change the descriptions of the codes to suite what they wanted them to say as well. The descriptions are not entered in a consitent manner either. Sometimes you may have to search for pain knee or sometimes the other way around such as back pain. Because it can take so long and is quite cumbersome for the doctor to search for the appropriate code (as well as not fully understanding coding) the doctor's pick the first code that appears in the very small window that comes close to what they are looking for or seems to be correct to them. This is resulting in incorrect codes constantly. Almost every progress note. Is there any solution to this? The codes in the claims get corrected but who should correct the codes in the progress note? For instance doctor chose code for bursitis but should be shoulder bursitis. The claims and progress notes are rarely matching. Is the doctor the only one who can correct the progress note? Does anyone else have the same problem? Any help or advice is greatly appreciated.