Medical Billing Forum
Coding => Coding => : Medbill12 December 13, 2019, 04:13:35 PM
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On some of our EHR medical records it shows the CPT codes and ICD10 codes that the physician chose. Sometimes those codes are incorrect and the coders may have to change the codes on the claim before we bill. Does the physician or coder have to re-open the medical record if the code is changed from what the physician chose? The documentation matches what the coder updated the codes to but the old CPT/ICD10 codes are still stamped on the bottom of the record. Not sure if it is mandatory to re-open the record and amend the CPT with the codes the coder changed to or if it is ok to leave since the actual documentation matches the codes billed.
I have received a couple different responses that conflict each other so any information would be great!
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My thoughts are that it does not have to be updated since the code being billed matches the documentation, however, I can see where that can be confusing. Since the EHR is being submitted (at least I'm assuming it is) for MACRA I believe it would be important that it is accurate. If it wasn't being submitted anywhere I would think it wouldn't matter since they are internal records only.
Anyone else?