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LNCtips.com: 2 Reasons to Review Billing Codes

As you know, billing codes are derived from injuries, illnesses, and procedures as a way to standardize descriptions of these disorders.  Three examples of billing codes are the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Diagnostic and Statistical Manual of Mental Disorders (DSM).  Healthcare providers list these codes on billing records and sometimes within the medical records themselves.  Chart auditors compare these billing codes to medical records for various reasons, such as to determine fraudulent billing.  I review billing codes also, but for two different reasons.

The first reason is that the handwriting in some medical records is atrocious.  I'm not talking about deciphering illegible handwriting.  I'm talking about not being able to pick out ANYTHING from the handwriting because it's so bad.  Psychiatrist records are the hardest ones for me to decipher.  Maybe it's because I don't have a psych background, but it seems that psychiatrists' handwritten notes in their office records go beyond the realm of bad handwriting into the territory of hieroglyphics.  By looking at the DSM codes, I can sometimes pick out a word or two in the medical records that relates to the diagnosis.  If I can't do that, I can at least tell the attorney what the working diagnosis was for the patient visits.  Thankfully, this problem is going away as healthcare providers switch to electronic medical records.  (As an aside, psychologist records are completely the opposite; every psychology record that I've reviewed has been neat and easy to read.  Do psychologists have to take penmanship courses to qualify for their PhDs?)

The second reason is that electronic medical records are voluminous for lengthy hospitalizations.  Using billing codes provides me with a shortcut to the records I want to review first, those related to medical malpractice allegations.  For example, I recently wanted to find out when a hospital performed a cranial ultrasound on a premature infant who was in the neonatal intensive care unit (NICU) for 39 days.  The records weren't searchable, and the attorney wanted the information right away.  In these NICU records, which contained thousands of pages, there wasn't a separate section for imaging studies.  Instead, lab and imaging study results were interspersed within the progress notes.  To make matters worse, the progress notes were repetitive.  When a physician wrote a progress note on the first day, that note was repeated on every subsequent day.  So on Day 39, it showed the physician's notes from Day 1, Day 2, Day 3, and so on.  The progress notes from the Day 39 page contained all the progress notes, but the lab and imaging studies only for Day 38.  To pin down the date of the cranial ultrasound, I looked at the billing records and found within a minute the code for the cranial ultrasound (CPT 76506) and when it was performed.  After that, I was able to find the study results quickly in the medical records.  I still reviewed all the medical records, but looking at the pertinent records first helped me to hone in on the case issues and meet the attorney's immediate request.  

Many billing records contain a description in addition to the code itself.  For example, billing records might list a cranial ultrasound with the code and a description such as "CR US."  If the billing records don't include a description and you're not sure what billing codes to look for, just Google the name of the test, procedure, or disease with the word "code" (without the quotes). 

You'll save time if you review billing records in situations such as these. Billing codes can help you make sense of both indecipherable handwritten and voluminous electronic medical records. 

Want to learn about LNC skills?  Check out the Archives.

...Katy Jones