jfuller@cwc4women.com
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We have an EMR system and the physicians pretty much code their own visits. They are OB/GYN's.
Recently, I received a request from Insurance for the office notes. The visit had already been paid and it was for a preventive visit (ie; well woman exam). Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility". The HPI was all about her infertility. The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap. The only mention of well woman exam was her diagnosis code and the cpt code. There was no age appropriate counseling.
I brought this to her attention and asked her what was up.
Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it. I told her she should have documented this fact somewhere in the visit.
Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
I had other billers/coders blind code the chart and none of them came up with a well woman exam.
Am I correct to be concerned?
Thanks,
Joni Fuller
Recently, I received a request from Insurance for the office notes. The visit had already been paid and it was for a preventive visit (ie; well woman exam). Upon reviewing the visit I noted that the patient actually came in for chief complaint of "infertility". The HPI was all about her infertility. The comments were all about her infertility. Although the physician did an exam, including breast, pelvic and a pap. The only mention of well woman exam was her diagnosis code and the cpt code. There was no age appropriate counseling.
I brought this to her attention and asked her what was up.
Her reply was that she could not do anything for the infertility and the patient was due for an annual, so she did it. I told her she should have documented this fact somewhere in the visit.
Our new practice administrator intervened and said "the notes look fine to me" and the exam meets the preventive well woman exam, so she over rode my recommendations and told the doctor I was wrong.
I fear a savvy auditor will take back payment and request we code this as an E/M with a diagnosis of "infertility" and of course the patient does not have coverage for this.
I had other billers/coders blind code the chart and none of them came up with a well woman exam.
Am I correct to be concerned?
Thanks,
Joni Fuller