Forum - Questions & Answers

Sep 17th, 2015 - TerryC 39 

charge entry help

Right now our doctors enter their own charges/dx's in the EHR in a unapplied field. The Medical Asst's also enter EKG,urine,tb test etc, int the same way. The MA's are not certified. I then check them all and "enter" them for billing. I also add any charges that may have been missed or query the doctor on any charges I see that may need changing. . My question is we recently were acquired from another entity. "Someone" from there said ONLY the doctor should be entering charges and if anything needed changed I should have them change it. Nobody else should be entering charges. Well if I had to go back to the doctors everytime there was something to add as EKG,UA dip etc. that they have documented in their notes I would never get anything done and they would also hate me. Right now I just add them. I only ask them if it happens to be a wrong charge or dx they put in. Does anybody know about this. I know there are people that enter charges for their doctors on the "notes/op notes". I am a certified coder. Sorry so long. Thanks

Sep 17th, 2015 - petunia 195 

re: charge entry help

I enter all of my providers charges. They may send a suggested code, if I agree I release the charge no questions asked. If I don't agree or they don't send me a code, I code it myself and send it to them for coding approval.

Sep 17th, 2015 -

re: charge entry help

The "Someone" that told you that is incorrect, as a coder myself I also enter all the chares after I have auditied the documentation that the providers have done to make sure that the correct CPT® code applies, that its not a bunlded procedure if more than one procedure is being done and that the correct modifiers are on the claim along with the correct DX code. If something has to be changed I also will query the providers and offer my suggestion as to how the cliam needs to be coded...that's what were hired for. It is up to the provider to provide us with the correct code and document for his services, but by no means is it stated that the provider enters all his own charges.

Sep 17th, 2015 - TerryC 39 

re: charge entry help

Thank you both, Exactly I think they are mis-informed or didn't state themselves correctly. Maybe I mis-understood. As long as it is stated somewhere what was done that's what data entry is for. Thank you



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