A community of 30,000 US Transcriptionist serving Medical Transcription Industry
Question for coders ... - CuriousMT
Posted: Dec 15, 2011
Just visiting your board to ask a question out of ignorance.
I'm an MT working for a hospital, doing straight transcription. There's been a growing trend for the hospitalists to dictate absolutely HUGE, long H&Ps/discharges ... including every stinkin' lab test and diagnostic procedure the patient has had for the last decade, it seems. Most of the reports are walls o' text, as these docs go on and on and bleepin' ON for at least four to five pages of transcribed dictation (most of it ESL, naturally).
When we commisserated with each other about the honkers at a recent staff meeting, the department head chimed in with "oh, but the coders love them!".
I thought, really? I couldn't imagine y'all enjoying having to plow through all that narrative to find what you need any more than we like slogging through the dictation. (Lines are lines, and at least we have work, noted and appreciated; but getting five or six of these in a row is exhausting.)
I will freely admit that I know next to nothing about how coders do their job, and that's why I'm asking: Was my manager correct, or just blowing smoke?
She was correct - Coder
[ In Reply To ..]Yes, we appreciate as much detail as we can get in the record. It helps us code. It makes our job EASIER.
We don't perceive it as slogging through anything. Inpatient coders typically enjoy reading the record and we are typically rather fast readers. It's a treasure hunt . . . the more things we can find, the happier we are. The more things the attending discusses and documents, the better off we are because we have a better chance of being able to use that information.
If you knew that all that detail you were transcribing was critically important in getting adequate reimbursement for your hospital's services, would that change your feelings? It isn't just that coders like it. We like it for a reason and that reason is that it enables us to code more accurately and to reflect the severity of illness more realistically, which allows us to get the reimbursement the facility deserves.
We read the entire record, anyway, you know. All of it. We just can't use anything that isn't directly addressed by the attending. When we see something we think needs to be documented by the attending, we have to query on it. That's time-consuming and delays everything, and sometimes never gets answered. That's another reason we appreciate the detailed reports.
You may perceive transcribing all that as drudgery. I was an MT once, so I have sympathy for you. I figured out tricks to help myself get through long reports. It's a little easier to bear if you understand that what you are doing has value. Definitely, more detailed reports have more value than the quick and sketchy ones.
It really does help to know this, thanks - CuriousMT
[ In Reply To ..]We always wonder, you know, if anyone actually reads what we work so hard to transcribe. I'm aware of the connection between what we do and the hospital (and therefore us) getting paid, also that coders are the essential link between the two. But it does help to picture a coder's pleasure at seeing one of these monsters as a treasure hunt, and knowing that the effort we put into them does make your job easier. Thanks for taking the time to explain it.
"addressed by the attending" - very interesting! - MTLC
[ In Reply To ..]I have often wondered about the value of dictation to the coder. I knew that dictated diagnoses and detail in OP reports was important. But I figured coders could just use the info in the chart about diagnostic/lab work and treatment provided.
So are you saying the attending has to write/dictate about anything that is done in order for it to be codable and thus potentially reimbursable?
Attending - jm
[ In Reply To ..]We can use documentation throughout the chart that is dictated by ALL the physicians as long as it isn̢۪t conflicting with the attending in the DS. If it is, then we have to query the physician for clarification. A very common one that I see is acute renal failure and acute renal insufficiency. Some doctors use these interchangeably, but code-wise they are not the same. So, if throughout the chart they document acute renal failure, and the attending documents acute renal insufficiency in the DS, we query. We can̢۪t code from labs or radiology results alone. We can code it if a doctor documents its significance. We are all about the words on the page, what is documented, so we read every sentence you transcribe! We are looking for clues.
This is great to know! I appreciate your taking the time - to explain. Thanks! MTLC (NM)
[ In Reply To ..]NM
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