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EMR vs Medical Coder - DJ

Posted: May 25, 2011

I hope this is not a dumb question, but do need some enlightening. I was at my doctor's office this morning and in the midst of the exam we got to talking about my goal to take the medical coding schooling (through Andrews). She was concerned that with the EMR process today, medical coders would not be as involved with actual coding as they have been in the past and therefore the job market not as promising. My doctor's clinic has the computer screen in the office and she showed me how she was entering my information into the medical record with the medical codes, etc. I don't know if I'm understanding correctly from others in the medical coding world or not, but, just because the doctor can pull down codes from a dropdown menu and insert them into the record doesn't necessarily mean that "that" particular code(s) is the end-all or be-all of the diagnosis does it? Or does it??? Don't medical coders need to review the EMR for additional codes to be applied or possible errors? I haven't started my medical coding class, so I'm not up on how the whole thing works. However, it made me curious as to how EMR and coding interact. Again, I hope my question wasn't too ignorant.....

It's a great question! Maybe Redpen will answer - My own thoughts

[ In Reply To ..]
When I see that people are coding from a pull-down menu, I remember how a few years ago hospitals experimented around with encoding machines and ended up costing themselves hundreds of thousands of dollars before bringing the certified coders back in.

On the other hand, if the pull-down menu is in a doctor's office or small clinic where they only do a certain number of procedures, always using the same codes, maybe the pull-down menu is equal to the old-fashioned Superbill. Doctors have always used the Superbill to just check off the procedure when they come out of the exam room, before handing it to the person who checks the patient out and gets their payment. In that case, nothing has changed. Doctors' offices rarely ever have a coder sitting their coding and clinics don't either. We never had those jobs and, with the new pull-down menu, still don't. In other words, nothing changed. Your doctor didn't have a real live coder there before and still doesn't. The doctor may not understand how complex things get outside the doctor's office though, in large clinics and hospitals.

By the way, I'm guessing I would get the same response from my doctor. He looks like a deer in headlights everytime I see him these days, with his head in his computer except when he's telling me how great it is or apologizing for the mistakes 'it' made. LOL.

EMR versus medical coder - wannabe coder

[ In Reply To ..]
Yes, the docs can select a code from a pull down menu but that does not necessarily mean it's accurate or that the appropriate modifiers have been assigned. Where I work, coders check and double check those codes to make sure they are accurate before it goes to the billing department. That is in the outpatient setting. Your doctor probably doesn't know much about how that works as long as he/she gets paid. Inpatient coding is more complex, where the hospital stay tells a "story" from the time a patient is admitted until they are discharged. Coders read the entire record and obtain a great deal of information from that patient stay, and codes have to be sequenced a certain way for Medicare/Medicaid billing, among other things. Coders are always there, functioning behind the scenes, just like the MTs who transcribe the dictation. The encoding software was never meant to replace human coders, it is an aid to help them do their jobs.

Every doctor I have ever worked for had someone that - does their coding.

[ In Reply To ..]
I did billing for about 5 years. The check-out person has to give all of the superbills to the billing clerk. Depending on how large the practice is to how many people you have in billing. They write a diagnosis and all procedures on the superbill, and then the person doing the billing enters in the codes. All clinics have to have someone entering in the codes unless they have EMR, and then they are automatically entered when the doctor picks the diagnosis and level of visit/procedures, etc.. I have also worked at an office with EMR. We still had someone reviewing all the codes. If injuries, making sure all info needed was in. Then we also had someone that just did the EOBs when they came in, but there were multiple providers.

The office (1 doctor) I work in now is going EMR very soon, and the lady that does our billing is worried as it will make less work for her not having to enter codes or charges.

Coding versus billing - Redpen

[ In Reply To ..]
I agree with those who responded previously.

There is a huge difference between coding and billing. The copying of codes that your doctor's EHR will eliminate is more billing than it is coding. Just because something involves code numbers doesn't make it coding.

I would not worry about this unless you have a desire to be one of those people who copies code numbers onto bills. If so, well, maybe you'll have fewer jobs to choose from. I don't think you want that kind of job, though. Doesn't sound like much fun.

Coding is a lot more than that. Way more. Not to mention that your doctor's office is going to have to hire someone to tell then what codes to put on the encounter form, to solve the mystery of rejected claims, to conduct periodic audits on the office coding and billing, to provide training, and to explain what Medicare really wants.

EMR vs Medical Coder - DJ

[ In Reply To ..]
Thank you for your replies and reassurance about medical coding. I'm looking forward to enrolling in class and starting this new career in January 2012!

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