Does your EMR display incomplete and inaccurate code descriptions?
Charge capture has moved from paper to the electronic health record (EHR) for many groups. I still fondly and longingly remember the paper encounter form. The clinician could very quickly indicate what service was performed, circle or write a diagnosis code, and order follow up, “Needs physical therapy referral.” “Return to clinic in 10 days.” It was quick and easy for the provider. Admittedly, the limited space for procedure and diagnosis code descriptions led to errors.
I thought that when we switched to electronic charge entry, the problem with incomplete and inaccurate code descriptions be a dim memory. After all, with unlimited pixels, why shouldn’t there be a complete CPT description? I was dead wrong. The descriptions of the CPT codes are not always accurate in electronic charging, leading clinicians to select the wrong code. Recently, I audited a note in which the patient was billed for dressing change, other than burn. The code selected by the physician was 15852, and it was described in the system as “dressing change.” However, the complete description of 15852 is “Dressing change (for other than burns) under anesthesia (other than local)” making it hardly likely that it was a service performed in the office. Likewise, code 11042 was selected by a physician, based on the description “debridement of skin.” The complete description of the code is Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less and the physician did not debride to the depth of subcutaneous tissue. The correct code for the service that was documented was 97598. In both of these instances, the practice was paid more money than it was entitled to collect. The Relative Value Units (RVUs) for the procedures selected was higher than the RVUs for the procedure that was documented.
In some cases, it’s impossible to tell from the charge capture page what code is selected. The description will be “lesion destruction” or “Medicare pap.” The physician can’t verify if the correct code is linked to the description.
Here’s a plea from this coding auditor: Display the complete CPT description for all codes during electronic charge entry. Don’t use the shortened version. Don’t allow anyone to modify or edit these descriptions to make the descriptions more user friendly. If you do, you run the risk of reporting the wrong CPT code, and collecting more or less money than you should have. And if it’s more, remember that you are required to return overpayments to government payers. If your charge capture system doesn’t display full descriptions, imagine that Captain Spock has issued a red alert and immediately add full descriptions. Verify that the descriptions are mapped to the correct CPT code.