Part B Insider (Multispecialty) Coding Alert
Case Goes To Trial Because Doctor Didn't Document Recommendation
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Good documentation doesn't just get paid, it can keep you out of trouble.
Case in point: Physician Rebecca Crouch says she recommended a colonoscopy and proctoscopy for Joseph Lee Amos after he complained of pain and rectal bleeding, but he refused them. Amos claims Crouch never mentioned the words -colonoscopy- or
-cancer,- and he was later diagnosed with colon cancer, requiring surgery and permanent colostomy.
A lower court granted Crouch's motion of dismissal, because Amos couldn't prove she didn't recommend those tests. But the Louisiana Second Circuit Court of Appeal reversed this decision, saying the lack of documentation in Crouch's files that would show she recommended a colonoscopy to Amos means a jury could conclude she never made the recommendation.
Part B Insider (Multispecialty) Coding Alert
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