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Adding diagnosis to a medical chart

Maiu Posted Mon 05th of December, 2011 19:12:53 PM

Are coders allowed to add diagnosis codes based on the medical record or is a doctor the only person allowed to add a diagnosis to a medical chart?

SuperCoder Answered Tue 06th of December, 2011 04:40:19 AM

Diagnosis will be given by the doctor and coders can only code for the diagnosis mentioned in the chart.

Maiu Posted Tue 06th of December, 2011 10:08:35 AM

Am I understanding it right that coders are allowed to add diagnosis codes based on the medical record?

SuperCoder Answered Tue 06th of December, 2011 11:40:41 AM

No, only doctors can mention about the appropirate diagnosis and coders can only code that.

Maiu Posted Tue 06th of December, 2011 13:27:24 PM

That's what I actually meant. A doctor will describe the diagnosis in the medical chart and the coder is allowed to attach a code to the diagnosis?

Maiu Posted Tue 06th of December, 2011 13:33:20 PM

I will give an exampe to clarify better: A doctor writes it the chart that patient has cough, but doesn't add a code 786.2 into the chart. Is coder allowed to add the code 786.2 based on what doctor wrote or is the doctor the only person who is allowed to add codes?

SuperCoder Answered Tue 06th of December, 2011 15:07:19 PM

Yes, the doctor writes "cough" in the chart, and the coder is allowed to code it as 786.2
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Practically, only in few cases, I have also witnessed in small practices where very limited number of codes are used. In such cases the doctors use to maintain a list of all those codes and code the charts themselves. Otherwise, coders are the persons who code the charts.

Maiu Posted Tue 06th of December, 2011 16:10:59 PM

Who assumes the legal responsibility of coding, the physician or the coder? Does the physician always have to sign off on the coding that was done based on the medical record?

SuperCoder Answered Wed 07th of December, 2011 06:34:04 AM

As Sanjit has mentioned in earlier post like if physician mentions in the chart for cough, coder job is to append Dx for cough. But rare practices what they are doing is doctors mentions a list of numeric codes and code the chart themselves. But here your question is who is legal responsiblity for coding?

Most often, the financial and legal responsibility will fall on the provider. He or she has responsibility for what is billed under his or her unique provider number and signature because the provider has signified that everything on the claim is accurate and has been reviewed and authenticated. A physician’s signature on a claim also attests that the medical services provided were necessary and reasonable to submit to a payor, therefore accumulating the accountability. It is for these reasons that the provider is usually the one that is fined for fraud and abuse. Do coders need to pay if it is their wrongdoing or mistake?

There is a level of liability that should be applied to anyone who knowingly submits a claim that is erroneous—this includes coders, billers, and physicians. The False Claims Act (FCA) imposes liability on any “persons” who knowingly submit false claims to the government for payment.

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