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Physicians can benefit from the talents of their medical assistants, and possibly in areas other than ICD-10.

Medical assistants (MAs) are typically members of physician office teams. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. They are among the first clinical team members to speak with patients, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states, placing, initiating, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the medical assistant may represent another option for doing so.

Given their understanding of medical terminology, and with an orientation on ICD-10 code requirements, these team members can quiz patients and capture some of the details often overlooked by physicians. They can save the physician time, supplement the physician’s documentation, and help the physician select a more specific code.

If we look at the ICD-10 injury elements, most of them can be captured in whole or in part by the MA in a short interview with the patient. Consider the following questions to ask:

  1. What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality as well.
  2. When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or whether the condition is a sequela.
  3. Where did it happen? Knowing the patient fell at home will not get us to the most specific code.  We need to know where in the home and sometimes even need to drill deeper as to the type of “home.”
  4. What was the patient status and what was the patient doing when the injury happened? Being bitten by a cat may be attributed to a patient status of “other,” but if the person bitten by the cat was a vet tech holding it to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.

This example shows us that with a little bit of prodding from the MA, we can get the additional information necessary for a specified code.

How about hierarchical condition categories (HCCs)? We know that these are driven by chronic conditions, and our physicians occasionally fall short of documenting all the conditions. A MA may be able to preview the patient’s health questionnaire and highlight conditions that the patient notes. The MA may be able to prompt the patient for some additional details on the condition, such as how long the patient has had the condition, whether another physician is treating the patient, or what medications the patient is taking.

Last week we discussed the benefit of scribes. The medical assistant may transcribe dictation for the practice already. Perhaps the MA could enter the physician’s findings into the electronic health record (EHR) as the physician dictates them while the physician examines the patient. This will save the physician time and may provide for a more comprehensive progress note in the EHR.

Finally, there’s the matter of medical necessity. The MA often is the individual who performs in-office testing. Medical assistants with a knowledge of NCDs/LCDs can prompt the physician to properly link the diagnosis with the test in order to avoid medical necessity denials.

Today, healthcare takes a village to complete its work. Utilizing the skills of medical assistants can help improve operational outcomes for the physician office. The American Association of Medical Assistants has published a lengthy list of functions (by state) that certified medical assistants are capable of performing. It may be worthwhile to utilize these team members to enhance ICD-10 coding and other operations.


Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

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