Submitting diagnosis codes to carrier without physician knowledge
We are asked to review/audit medical records, and submit diagnosis codes found in documentation to CMS and the physician has no knowledge this is being done. We may add codes or correct incorrect codes submitted without physician approval. Plus we have been told to code from the chief complaint, and to code using a code category vs code to highest level of specifity, and this is under the medicare risk program. If you code to highest level, there is no risk score, thus no funding, a code category has a risk score with funding.
