• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

2nd REQUEST ADVISE PLEASE!!

Messages
36
Best answers
0
How to you go about coding for E/M services (mainly inpatient) when the physician uses a templete and everything (even the exam) is consistant from one DOS to another? Do they get credit??
 

jmcpolin

True Blue
Messages
841
Location
Midvale, UT
Best answers
0
That is considered "cloning" and can throw up a red flag, it is not wise to copy and paste the same information over and over. Your physician needs to make each document unique from the other previous notes.
 
Messages
36
Best answers
0
I know it's considered cloning but my question is do you go ahead and code and be ready for an audit or do you say they are not billable because they are clones of the orignial dos?
 

merielin

New
Messages
3
Best answers
0
Red Flag!

This is a huge audit risk. As a matter of fact, the coders in my facility recently refused to post charges for a provider who was obviously copy/pasting. If all of the information in an inpatient record is verbatim from day to day, how do you prove medical necessity for the stay? And if they are discharged in the same condition they were admitted in, that documentation would be begging for malpractice suits. My best advice is not to bill this. Your certification is at stake if you bill something you know is incorrect. Talk to your provider about the risks of his/her documentation. Chances are, he or she is completely capable of providing more detailed information about the case and will do so once they understand the importance of the documentation.
 
Top