sspeer
Contributor
I have had a problem with a physician for years. His documentation is poor and even when there is a diagnosis, he isn't really specific when he chooses his diagnosis. It's usually unspecified. I don't know why I have so many issues with him and it is definitely worse now with ICD 10. I have my AAS in medical assisting so I know that I tend to go above coding only and review his documentation on the medical assisting side as well.
Since we are using an EMR and the E/m is populated at the end of a visit, I spend most of my time on diagnosis, cpt, modifier and chart reveiws.
I have a hard time when the doc doesn't code symptoms but codes a medical diagnosis when there is no testing to prove the diagnosis. Ie, appendicitis, fracture. I will typically hold the claim for results before coding and billing. If there diagnosis isn't confirmed I will code symptoms. I don't want any incorrect medical history going to someone's insurance company and creating problems for them in the future. Another issue, when I code a diagnosis to the highest specificity, it affects the practice management / billing side of the EMR only. What happens if/when we are audited and the coding doesn't match exactly to what the physician coded?
Every day I code, I create an excel spreadsheet and list each patient that is missing documentation for a diagnosis given, note to doc if I see a complaint that doesn't appear to be addressed in visit (although it may have), and also request infomation on a missing diagnosis for a medication prescribed. This happens with about 75% of charts.
Is this what others do? Help, it drives me crazy.
Since we are using an EMR and the E/m is populated at the end of a visit, I spend most of my time on diagnosis, cpt, modifier and chart reveiws.
I have a hard time when the doc doesn't code symptoms but codes a medical diagnosis when there is no testing to prove the diagnosis. Ie, appendicitis, fracture. I will typically hold the claim for results before coding and billing. If there diagnosis isn't confirmed I will code symptoms. I don't want any incorrect medical history going to someone's insurance company and creating problems for them in the future. Another issue, when I code a diagnosis to the highest specificity, it affects the practice management / billing side of the EMR only. What happens if/when we are audited and the coding doesn't match exactly to what the physician coded?
Every day I code, I create an excel spreadsheet and list each patient that is missing documentation for a diagnosis given, note to doc if I see a complaint that doesn't appear to be addressed in visit (although it may have), and also request infomation on a missing diagnosis for a medication prescribed. This happens with about 75% of charts.
Is this what others do? Help, it drives me crazy.