November 15, 2016

Hi Jennifer,
I am a regular reader of your column and appreciate your insights.

I have a question for you. We are a non-profit organization that runs a busy Article 28 clinic.  We have trouble hiring coders who stay on for long.  They get a few months of experience and then move on.  Currently we are without a coder.   Our doctors do not have time to select the codes on the superbills, so they would like for someone else to select the codes based on their detailed visit notes.  We have heard different requirements from different sources (mainly coders who state that only coders can select the codes), but I can’t find this in writing.  I would like for our LPN to review the doctor’s notes in the medical record and provide coding on the superbill, and then send it back to the physician to approve.  Would you please comment on this and also point out the regulations that guide this.  Thank you!


I've asked Jackie Thelian, President of Medco Consultants to answer this because she is the expert (Jackie, who is endorsed by most medical societies in this state is a certified coder educator and also available part of the time to audit and provide preventative coding and documentation advice - she does book up very quickly for annual reviews. So, thank you Jackie!) - 

Hi Jennifer:

There is no hard and fast rule that says who should code, however it is important keep the following in mind. 

The ultimate responsibility belongs to the physician or qualified healthcare professional (QHP). It is the physician/QHP who can get audited -- not the billing person, LPN or the certified coder, therefore the physician is responsible for any errors made. 

Ideally, the coding process is a shared responsibility. Typically what we currently see with the implementation of the Electronic Health Record, is the physician/QHP  selects the codes and the coder/biller/LPN will review the codes and run them through a claims scrubber software. If there are any changes the coder, biller, LPN, feels should be made they are usually reviewed with the physician/QHP  who will approve them or not.

This process also works as a teaching opportunity, as each time the coder/biller/LPN goes over the changes it helps the physician/QHP to better understand the coding process. 

Bottom line, it makes no difference who selects the codes in the first place as long as the physician/QHP approves the codes, because ultimately it is the physician/QHP who is responsible.

To contact Jackie directly call or visit her website at: Medco Consultants, Inc. Jacqueline Thelian, CPC, CPC-I, CHCA - 718-217-3802 or