Ongoing education and the right tools and resources can help physicians as they face increased coding responsibilities.
Twenty-five years ago in outpatient settings, doctors dictated notes using narratives and appropriate medical jargon to describe a patient’s presenting diagnoses. Samuel L. Church, MD, MPH, CPC, CRC, CPC-I, Georgia-local medical director at Aledade, Inc, remembers that coding happened after the dictation, apart from the physician. “It kind of happened magically,” he says. “We never had to worry about [coding] then. We were concentrating on doing good medicine.”
Today, however, the landscape has shifted. Physicians are often tasked with at least some of the coding responsibilities as they input notes into EMRs. “We get to these electronic records where we are asked to provide a specific diagnosis code. Ultimately, the doctor or the provider is the one who is responsible for the code. We have to do it at the time of the note signing,” Church says.
For The Record»