Wiki Please help emr dx issues

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dls

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I am very confused on some EMR Dx issues, in need of help. Our EMR has the smart search for Dr to put Dx in the assessment area. My problem is that my practice manager says that I can not change or add to this, meaning I have to use what he puts even when I know they are wrong and that some important one are missing. I have to have him change or add. My question is this true by officials guidelines with EMR somewhere? Me being the coder/biller isn't it my job to populate the HCFFA correctly?
 
dls said:
I am very confused on some EMR Dx issues, in need of help. Our EMR has the smart search for Dr to put Dx in the assessment area. My problem is that my practice manager says that I can not change or add to this, meaning I have to use what he puts even when I know they are wrong and that some important one are missing. I have to have him change or add. My question is this true by officials guidelines with EMR somewhere? Me being the coder/biller isn't it my job to populate the HCFFA correctly?
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You cannot change what he puts in the assessment, however the codes you put on the claim must match what he has documented in the body of the note. It is not a problem if the codes on the note do not match the code numbers in the dx listing of the note.
 
Thank you Debra. we use E clinical works and my practice manger is telling me that the assessment codes he puts in have to be on the HCFFA as well. Is there any literature that you know of I can show here?
 
I dont know of anything that says one way or the other, except that the documentation must support the codes on the claim. There are several Coding Clinics that state this but you must pay to get those.
 
So if a patient has CAD, but Dr does not put it in assessments but it's in medical history and it's put in CC can I code it?
 
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