A community of 30,000 US Transcriptionist serving Medical Transcription Industry

question for current coders - cj

Posted: May 13, 2014

Have coding processes changed recently at your facilities? I work for a very large hospital, a level I trauma center and teaching facility. I work on the outpatient side. We have strict productivity guidelines not only in terms of charts per hour but also percentage of productive time. Our volumes are huge and are supposed to be coding within 1.5 to 2 days post discharge. It seems like they have found more and more ways to cut corners in order to push more charts out the door, obviously in an effor to collect the bills. We code from Chief complaint and final impression only, thus skip all the histories (medical history, surgery history, social such as smoking history, meds, etc. Being an old timer, I am having a big problem with this type of coding and just wonder if anyone else is noticing anything similar going on. I want to do the job right, not just fast. Has anyone noticed their focus changing to more quantity and away from quality first? Although I am only a couple of years from retirement, I am considering looking at a job change. don't want to make a move if it will be more of the same wherever I go.

Nope, not happening here. - sm

[ In Reply To ..]
I have heard of places that code only the discharge diagnoses without looking at anything else, but I have not seen it. Definitely not where I work.

That's kind of misguided, if you ask me. If you don't read the record, how are you supposed to know if something was POA? How are you supposed to identify complications and comorbidities that were not documented, so you can query?

Someone in management is being short-sighted. They are putting immediate turn-around before revenue. Sounds like they don't understand coding. Sounds like they didn't get the message about using all available documentation.

That being said, a question for you. What are you coding from the history?

That's the question in their minds. They are wondering why you would need to do that. They think the info you need is in the final dxs. They think the doctors know just what to tell you and where to say it.

I would want to have this as a written policy, because I would not want the lost revenue and CMS audit findings coming back to haunt me. I would sure be looking for another job, too.

Bottom Dollar - CT

[ In Reply To ..]
It would be interesting to see the same chart coded both ways, correctly and expeditiously. Would the additional revenues garnered from a more comprehensive approach outweigh the additional costs from delayed payment and employee costs? Being able to spark change often time comes from being able to show how the revenue cycle is being affected by past, current, and potentially future changes. Of course, this doesn't even begin to approach the effect it may have on quality to do this sort of coding...

It is actually possible to code a chart meeting - Both requirements

[ In Reply To ..]
We code charts accurately and expeditiously every day. Not sure why you think it has to be either/or.

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