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I came across a circumstance in my work place where a coder was doing preprospective auditing on a note from an E/M visit and the documentation did not meet the level of service that the doctor selected even though the visit did qualify for this particular level.The coder went back to the physicain and had her do an addendum to code based on time so that it could be billed with the level selected.I was told that once a note is audited this is not allowed.What is the correct thing to do?
 
I may be misinterpreting your question

I'm not sure I'm correctly interpreting the scenario but ...

Our coders will occassionaly review documentation - BEFORE actually sending out a claim. These kind of spot check, prospective audits, are NOT true audits. If there is a discrepancy between the level on the encounter form and the documentation, the coder gives the physician the option ... "we can code level X which is documented, or you can amend your documentation to meet the level you chose."

Sometimes it's an oversight ... physicians DO get interrupted mid dictation ...

You are correct, however, that once a service has been coded and billed, and you receive an official audit, then NO, you cannot change your documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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