Can I bill without an operative report?

[tiwallace]

Our Docs sometimes do not dictate in a timely manner. Can I bill without one? I need documentation on the answer.

[cheermom68]

I would never code and bill without an op report. If you do not have the report you cannot accurately determine what code is correct.

LeeAnn

[mvd851]

Iagree with LeAnn. Remember what you learned over and over "NOT DOCUMENTED NOT DONE". How can you support ypur coding without documentation.

[tiwallace]

I agree with you. Do you know of documentation stating that? I am being told that I should after 30 days so as not to miss the filing deadline. I would like to give documentation to my reply.

[Lujanwj]

Hopefully, we all agree with LeeAnn. You should never bill without documentation. In addition, you should never code from the Operative Note Operation Summary. Often times DR's automatically put in procedures they routinely do in the summary but not always performed and that goes both ways - they also miss a lot of stuff they didn't know they could bill for.
You don't need documentation telling you this, you need the thought of an auditor coming and you trying to explain how you billed what you billed without an OpNote

[vpappas1962]

To code without an operative report could be considered fraudulent. You might upcode or undercode (both are wrong). As a coder we all know the "golden rule" which was mentioned above. If you are being asked to do something that you don't feel comfortable doing, then go to your manager. If this doesn't work, then find another job. Is it worth it to be fined and lose your certification?