It’s a typical day in the life of a provider, you’ve drank your first cup of coffee (well at least 1), you’ve made your way into the office and are getting settled in. You have started your computer because in this day and age there is no such thing as paper charts anymore. As you’re looking over your schedule, you see poor little Mrs. Huckleberry is coming in for a visit at 9:15 am which is not particularly who you would like to see this early in the morning but every patient deserves your utmost time and attention. Mrs. Huckleberry has been a patient for 10 years and has probably 30 different diagnoses in her chart, but today she is coming in for a 3 month check of her chronic conditions. Lisa (the medical assistant) kindly calls Mrs. Huckleberry back and takes all her vitals. Lisa enters all the information into the EHR system you use. After getting all the required information Lisa asks Mrs. Huckleberry why she is here for a visit today? Ever so sweetly Mrs. Huckleberry states that she is just here for her 3 month check-up. Lisa notates this in her electronic chart and lets Mrs. Huckleberry know that Dr. Finn will be in soon!
Upon entering the room you kindly greet Mrs. Huckleberry and begin discussing her chronic conditions of hypertension (401.1), hyperlipidemia (272.4), asthma (493.90). You bid Mrs. Huckleberry adieu and proceed to your office to work on her office note. As with most EHR systems you have the ability to “pull over” diagnosis codes from previous visits so to save time you go ahead and pull them over.
This is NOT what you should do in this particular case. Mrs. Huckleberry was only seen for her chronic conditions of hypertension, hyperlipidemia, and asthma. All those other diagnosis codes have absolutely nothing to do with her visit and are not supported by your office note. Although, it is a time of technological advancement and the use of EHR is to make things simpler that does not mean that all codes match all visits! As the provider you should only code exactly what the patient was seen for at that visit to make sure the diagnosis codes billed match the chief complaint and history of present illness in your note.
Since Dr. Finn decided to pull over all the previous 30 diagnosis codes he now is dealing with the wrath of Polly (his billing specialist). Polly tells Dr. Finn that what he is billing doesn’t match his note, and this is delaying submitting the claim for payment. Polly knows when she talks $$ Dr. Finn will listen. After Dr. Finn endures Polly’s wrath he corrects the diagnosis codes to match the reason for the visit. Polly happily tells Dr. Finn his note now looks fantastic and payment should come quickly! Dr. Finn and Polly are now friends again and life is happy in Twain Family Practice, LLC.
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