Keep Electronic Medical Records (EMR) up to date with the latest diagnosis codes
While EMR are intended to allow physicians to keep all information in one place and easily share records between provider offices, this is possible only if providers and staff maintain the EMR on a regular basis. Who has the ownership of updating this in your office?
Connect the chief complaint (or the reason for the visit) to what is being addressed and evaluated
We understand that most coders need to meet productivity standards, however, it is also extremely important to focus on quality and utilization of the most accurate codes available. Coding accuracy requires continual learning. Codes have the potential to change in October and April of every year. Although it is rare, there have been occasions where a random change happens between those times as well. If you are reviewing a record and something seems missing, question before coding. Specificity is one of the top ways to maintain coding accuracy!
When coding a record, be aware that any record you submit a code for is subject to an audit by several entities. These include CMS, NCQA, and the OIG just to name a few, and unfortunately these requests can go back several years and can carry a large impact on revenue. Auditors verify that medical records reflect the care provided and that coding corresponds to their diagnoses and procedures. They check for completeness, accuracy, coding, and documentation standards’ compliance.
Below are a few coding pitfalls to avoid coding errors, which impact care and revenue:
Think before you code! Does the information given support the codes you are using? The time to question is before you code, not as an afterthought!
Moving forward, our plan is to bring you the GOOD, the Bad and occasionally the Ugly when we see it in the coding world of our records and to keep you informed of any changes. We are always open to any questions or comments regarding coding. We can be reached at riskadjustment@htanc.com.
Let’s work as a team to strive for the GOLD standard of documentation!