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Path of the medical record - Correct me if I am wrong

Posted: Mar 31, 2010

I'm trying to follow the path of a patient medical record. Pls correct me if I'm wrong. But here's my understanding: the doctor dictates (or inputs his data), then it goes to coding. From coding it goes to billing and from billing it goes to the designated payor (insurance company, medicare, etc). So If my scenario is correct, then if there is not an accurate record, then it can't be coded correctly and it can't be billed correctly and the medical faciility does not get paid correctly. Hence the need for an accurate record which is in short supply using offshore, EMR point and click and most VR. Correct me if I'm wrong. Anybody?

Medical record path..sm - MT68

[ In Reply To ..]
Having worked as an MA and surgical coordinator as well as an MT, usually after a patient sees the doctor, the doctor will circle/check off the CPT code(s) on the billing/routing slip as to what type/level of visit was done, lab tests, etc., also that billing slip will go with the patient to xray for the tech to check off or circle what they have done. What they are circling is the CPT code and then an ICD 9 (diagnosis code is needed) is usually given by the doctor (most docs know their codes to their specialty). Not all insurance companies require dictation to process a claim and most claims are submitted electronically sometimes before the notes are done, hence, the need for 24 TAT when it comes to WC and most ORTHO (that's what I have worked in) since with most MRIs authos and testing the WC adjuster needs to see if the patient has the symptoms and/or diagnosis to warrant the procedure and before they will approve it. Medicare doesn't give a hoot about the dictation to okay a procedure.

Most coders/billers are using the billing slip to process claims, not the dictation. They may verify or double check something if they need to, but initially they are billing off of that billing/routing slip that is on the patient's chart whether it is paper chart or EMR.

It would be nice to see some docs using inhouse MTs as Scribes to travel room to room with them and transcribe and/or point/click with them during the visit with the patient...that would be great!!

Yes, you're correct, but here's more explanation - Reden

[ In Reply To ..]
Yes, the doctor produces his documentation, which then goes to coding. Coding abstracts the diagnosis and procedure codes, which then go to billing. The claim is sent to an insurer who pays if the diagnosis and procedure codes make it through some computer checks which determine if the claim makes sense or not, is within the payer's guidelines or not, etc. If the payer's computer thinks it looks odd, it will be denied and the facility has to figure out what is wrong, fix it, and possibly then send a copy of the documentation with it. Even if the payer doesn't ask for documentation then, they might at a later date during an audit, in which case the documentation had better match up, or they'll demand a refund.

An accurate record, however, doesn't mean a nicely formatted, lengthy, verbose report written in perfect English. It just has to include all the information that the insurer expects to see. They key concept being "if it isn't documented, it wasn't done." A provider cannot bill for a EKG if there is no copy of the tracing and no written interpretation (just "normal" isn't an interpretation). A cast did not get applied to that broken bone unless the process is described. A laceration of 3.5 cm did not get sutured unless it is clearly described as 3.5 cm.

Where does the nicely done record come into play? It helps communicate information to other providers and it can make or break a court case.

In an office, yes, the coding is often done by a physician who marks a charge ticket. If this is his office, he is responsible for the accuracy of the coding. It's not likely that he has a full-fledged coder, however. He may just employ a biller to transfer the codes to the claim form. Some offices have multi-tasking MAs or LPNs who do a variety of chores, including sending out claims. But, this isn't "coding"--it's just billing.

Coders can be held responsible for the accuracy of the claim. If the physician is engaged in fraud or abuse, the coder can be nailed along with him. Coders therefore typically determine the codes themselves. If a physician wishes to do it himself, the bona fide coder may come in once or twice a year to help make sure the charge ticket is correct and to audit the coding and billing so that the physician can feel confident and also demonstrate that he has a compliance program, thus defusing potential sanctions in the event of errors.

Coders don't just assign codes--it's not a clerical function. They serve a dual function of assigning codes and assuring that the supporting documentation is sufficient to stand up to scrutiny.

When I code a record, my name goes on it, and I'm responsible for the accuracy of the coding. If I think the documentation isn't sufficient, I ask for it to be amended. When I sign off on it, that says that the documentation is sufficient to support the codes I assigned and that the codes are honest. I tell physicians what information needs to be documented and what the payer requirements are. I work with the expectation that I will uphold this in court. That's a lot more than just copying codes onto a claim.

In a facility, the facility becomes responsible for its own coding. That coding will be based on the physician's documentation, so the facility will encourage the physician to document appropriately. Physicians do not tell the facility what codes to use. A coder reads the entire record to extract the necessary information, asking for clarification when necessary. Again, the coder is responsible for his or her work--responsible to the facility, which is ultimately responsible.

I think the confusion comes in the difference ..... - travelinMT

[ In Reply To ..]
Between Office coding and Hospital coding. Office coding as was explained previously is for the most part acutally coded by the doc on the office treatment slip. Office coding uses CPT codes with an ICD9 code for a diagnosis and again as earlier explained is 99% of the time circled by the doc on that slip. The slips are basically pre-printed with all the types of treatment that is done in the particular office. The hospital billing requires someone that can go through the acutal chart and based on the treatment information in that chart assign an ICD9 code to all the hospital treatments that were done.

The are two different animals, you are either coding for the hospital or you are coding for the physician and the hospital coding is much more complicated that the physician/office coding is. Both require coding to be done before billing can be done as the billing amounts go off of the fee schedules that give an allowance for each specific code. Those fee schedules do vary by geographic areas, ie: Washington, DC charges are going to be higher than El Paso, Texas.

I think there is some confusion amongst people who say they want to go into billing and coding as to the fact that Hospital and Physician Office coding are two very different jobs with two very different levels of education needed to accurately do the job.

A little more . . . - Redpen

[ In Reply To ..]
You're correct that there is a difference between office and hospital coding. However, there are very large numbers of physician services coders who would be very upset to hear that their education is a different level than that of hospital coders, because it isn't.

Yes, there is a difference between office and hospital coding, but neither office nor hospital coding are that cut and dried. Not all offices rely on physician check-offs and not all hospital coding is the coding of inpatient stays.

I'll try to explain the spectrum of coding so this will be more clear.

Medical care is provided in a variety of locations. These vary according to the type of organization providing the care.

At one end, there are small physician offices whose doctors never visit a hospital. Those practices can usually get away with physician check-off on a charge ticket. Processing this work is called "billing," not coding.

Some physicians also see hospitalized patients, but without performing tests or procedures. This requires a different type of E/M code, but the check-off method still may work.

Radiology and lab can often be automated, their coding is so predictable.

Surgeons may have offices, see patients in the hospital, and perform surgical procedures. This coding is more complex and begins to require a professional coder, particularly if it is a large practice. The coder might only need to be familiar with one specialty.

Cardiologists who do invasive procedures and interventional radiologists not only require a professional coder, but one which is specially certified. At this point, the procedures are high-dollar and the coding is so complex that it isn't cost effective for the physicians to do their own coding. (This coding is often more difficult than inpatient coding.)

All of the above is coded using ICD-9-CM diagnosis codes with CPT procedures.
Those surgeons/cardiologists/interventional radiologist have to do their ambulatory procedures somewhere, and that somewhere might be an ambulatory facility, either free-standing or associated with a hospital. The facility bills for its services separately, again using ICD-9-CM and CPT codes. These facilities employ professional coders. It would not be wise for them to rely on physician-chosen codes. The facilities might provide coding services for the physicians as a side benefit. The more variety in the procedures performed at the facility, the more skilled the coder needs to be.

Those same physicians have to do their non-ambulatory, i.e., inpatient, procedures somewhere, and that is at a hospital where the patient is admitted. Those physicians will likely code their own patient visits, might code the part of their procedures billed by their office (the "professional service" portion), but will not code the hospital's portion of the surgical procedures or the inpatient stay. Those are coded by the facility itself, and for an inpatient are coded using ICD-9-CM diagnosis and procedure codes.

Not all physicians practice out of their own offices, either. Some types of facilities, especially large healthcare systems, employ the physicians. Those entities use professional coders because it is in their best interests to do so. Coding in such facilities is so complex that coders may specialize in one type of coding or another, such as outpatient, surgery, ER, or inpatient.

Small offices which rely on physician check-offs make up only a very small portion of coding situations. The level of knowledge required to do that job is less, but that is because it's not really coding yet -- it's just claims processing. Those kinds of jobs can be useful entry-level positions for new coders and student coders.

Beyond that, there is a whole world of outpatient and ambulatory coding that does not rely on physician check-offs and which requires the same level of knowledge as inpatient coding. In some cases, it may require more.

There are no hard and fast rules in coding, and coding is far more complex than it appears on the surface.

It's a lot like a kitchen. You might drink from a jelly glass and eat off a plastic dish when standing in the kitchen, but when the whole family and guests come over for festive holiday meals, you're going to put out the good china and glassware.

Thanks for that great explanation of the difference - Billing vs Coding

[ In Reply To ..]
That's the best explanation I've ever seen of the difference between billers and coders.

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