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Impact of EPIC on coding - me

Posted: Feb 26, 2012

I was reading a post on one of the other boards about what an EPIC or point-and-click report looks like and it made me think about what it would be like to code a report like that. Was wondering if any coders here code EMR point-and-click reports and does it make your job harder? I would think that lots of narrative and detail would be more helpful in coding. I've never actually seen an EPIC report so I don't know. Thanks.

Answer - Coder

[ In Reply To ..]
In order to code, you have to see the service and diagnoses documented in written form. It is not enough for a doctor to say he did a 99245 and justify it with "because I said I did it."

In the 60s and 70s, doctors and hospitals got paid by writing a bill . . . period. Now, they have to justify it. If there is inadequate evidence of what they did and why they did it in the record, they cannot bill it. They have to show that it was medically necessary and that it met appropriate standards of care. It has to meet Medicare standards in many cases and possibly those of another insurer.

It makes no difference if this is handwritten, dictated, or point and click. If the end result is inadequate, it cannot be coded and you do not get paid.

Coders, however, are not in the same boat as MTs faced with crummy dictation. We do not just sit there unable to do anything about it. We are expected to educate and correct the problem. We identify what is needed and get it added.

That is why we get paid what we do . . . we earn money for providers. We find lost revenue and retrieve it. We keep our employers from being audited and having to refund what they got paid. We keep them out of jail, or at least in business.

Some small providers do not have a coder on staff but use a consulting coder. Hey are very well paid. They come in to do audits and advise on what the documentation should contain and on the billing.

Larger providers employ coders who are expected to correct problems as they encounter them. They query, they advise, and they provide education. They keep up with requirements and make sure the providers meet them.

Large providers also employ coders in documentation review and improvement roles. They may also work on developing the point and click templates. I spent time last week observing a provider perform a procedure over and over so I could write a point and click procedure note. MT background helps with that. I do not take what they think they should say but what I know has to be there from a coding standpoint from Medicare rules, and from quality of care standards.

Medicare is now taking a closer look at templated documentation. They object to cookie-cutter sameness where every note says the same thing and it appears fraudulent. More jobs for coding and documentation specialists!

Thanks Coder! - me

[ In Reply To ..]
What a great answer! You have given me a lot to think about. My impression of coding so far (module 1 at Andrews) has been one of looking up diagnoses and applying codes. Haven't really been seeing the big picture, what all is involved. I did not realize coders had a hand in developing the templates, that is so exciting, but not really surprising when I think about it, who better? Thanks for volunteering your time here on this board to help us widen our horizons!

Looking up dxs - Coder

[ In Reply To ..]
Yes, at this stage you can get a limited view of coding. It can seem that it is just looking up codes. That is a basic skill that underlies everything we do, so you have to become good at it. I think Andrews does a lot more of that than other programs might and does it more thoroughly, which may be a large part of the reason their grads are able to pass certification exams.

Surgeons have to spend a lot of time learning to tie sutures. Court reporters have to spend a lot of time learning their shorthand. You had to spend a lot of time learning to keyboard before you could do MT, even if you did it years before, and you had to spend a lot of time training your ears. For coders, the equivalent is what you are doing now.

answer - coder - jan2

[ In Reply To ..]
Just re-read your wonderful, enlightening post and have a question. In your 4th paragraph, "We identify...and get it added." Do you mean that a patient's medical report will get revised? Is that allowed? Doesn't the insurance company or whoever see it and realize it has been "tampered with?" Thanks.

Addendum, not tampering - Coder

[ In Reply To ..]
Amending documentation is perfectly fine. That is how your transcribed reports, once signed, are added to or corrected. The original remains along with the amendment.

Let's say we need to know how long a wound was because the repair code is based on length. If it was not documented, it has to be added. If a drug was administered, but we do not know how much, it has to be added. If a knee was injected but it does not say which, it has to be added.

You can see why those would not be a problem. In other situations, we may see that something probably happened but was not documented in enough clarity to allow coding that would result in - watch how I say this - payment at a rate that would better account for the facility's expenses in teating the patient, we might query the provider to point out what we saw and inquire if the provider would consider amending his documentation. "...cultures showing blah blah, administration of blah blah antibiotic, white count of blah blah" etc. "If you feel ... appropriate ... blah blah." They amend with something similar, stating the omitted diagnosis and justifying it.

There is some degree of skill required to do this in an appropriate fashion. You cannot just phone them up or send an email saying "Hey, if you would add diagnosis of gram-negative pneumonia we could get a lot more money"

You also expect them to learn from the process. You should not be amending every procedure with a statement of how long something is that appears to be in cahoots with someone who tells you exactly how many millimeters to add to bunp it up a notch.

It would also appear odd if the documentation gave one diagnosis that did not happen to meet medical necessity and an addendum was added changing it to something that justified doing a procedure but was unrelated to the problem described previously. If you do that just to get it paid, it is not ok.

It is a fine line. That is one of the things that makes it interesting work. Also one of the reasons it requires a brain. And pays well.

Some people do not enjoy that much ambiguity and complex decision-making, or the amount of research that goes with it, or the need to keep up with it all. Some coding jobs require less of this than others.

addendum - anon

[ In Reply To ..]
I am a CMT and also currently studying coding. I just this morning typed an "addendum" to a discharge summary from a month ago. The physician dictated he was queried whether sepsis was present. He then went on to dictate specific lab findings and reasons that sepsis should/could be added as an addendum.

Yup, that's how you do it! - nm

[ In Reply To ..]
nm

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