Question Amending Medical Records

beavert

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A provider is billing for critical care (99291-99292) but does not document time. They want to send it back to the provider to add time a week later. Is this appropriate? I was always under the impression that how can they remember how much time they spent if it was not originally documented. The claim has not gone out yet.
 

thomas7331

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Most physician query guidelines specify that the queries should made for clarification and be prompted by clinical indicators in the medical record, and that queries should not be made solely for purposes of billing or reimbursement. In my opinion, there would be little clinical justification in querying a provider solely in order to add documentation of time to a critical care note. I agree with you that physicians would not likely have an accurate recollection of the number of minutes spent with a patient a week earlier (and, for what it's worth, I would predict that the record would come back with '35 minutes', which in my experience seems to be the default time that physicians use to document most critical care anyway). If this is an isolated instance then it would likely not be a major issue, but as a routine practice, this could certainly be of questionable compliance.
 
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I would think that the only acceptable way (that comes to my mind) is noting how much time was spent when it is noted after the fact would be something like this:

ADDENDUM: I failed to note the time spent on critical care of this patient on xx/xx/xx. I reviewed the EKG of XX/XX/XX, I (blah blah blah - etc - list it all out). Conservatively, these activities could take as few as 10 minutes and as many as 360 minutes. Due to the amount of time that has lapsed since these activities occurred, I am declaring my time spent as the most conservative estimate, that being 10 minutes.

That way, I don't think anyone could realistically say that he is trying to pad the time, make it up, or do anything other than be paid for the most conservative time possible. Then give him a figurative smack upside the head and tell him how much money was lost because he didn't note the time spent.
 

thomas7331

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I would think that the only acceptable way (that comes to my mind) is noting how much time was spent when it is noted after the fact would be something like this:

ADDENDUM: I failed to note the time spent on critical care of this patient on xx/xx/xx. I reviewed the EKG of XX/XX/XX, I (blah blah blah - etc - list it all out). Conservatively, these activities could take as few as 10 minutes and as many as 360 minutes. Due to the amount of time that has lapsed since these activities occurred, I am declaring my time spent as the most conservative estimate, that being 10 minutes.

That way, I don't think anyone could realistically say that he is trying to pad the time, make it up, or do anything other than be paid for the most conservative time possible. Then give him a figurative smack upside the head and tell him how much money was lost because he didn't note the time spent.
Well, in an ideal world maybe. One can become cynical in this business. Ultimately, though, I don't think it's up to coders to decide whether or not we are going to believe what providers write, or to make up our own standards as to what we will 'accept' so it's best to steer clear of that kind of thinking in the workplace. And we certainly can't query a provider to document the way we wish they would. So if a provider attests that they spent 35 minutes, then as a coder, I code that they spent 35 minutes. If they didn't really spend 35 minutes or they don't actually remember, well, then that's on them.
 
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Well, in an ideal world maybe. One can become cynical in this business. Ultimately, though, I don't think it's up to coders to decide whether or not we are going to believe what providers write, or to make up our own standards as to what we will 'accept' so it's best to steer clear of that kind of thinking in the workplace. And we certainly can't query a provider to document the way we wish they would. So if a provider attests that they spent 35 minutes, then as a coder, I code that they spent 35 minutes. If they didn't really spend 35 minutes or they don't actually remember, well, then that's on them.
I am the biller, the coder, the office manager, the legal department, the personal secretary, the everything for my provider. My goal is to keep his butt out of prison, keep his license clear, and keep his practice thriving so I keep my job. That is the type of advice I give him. I can certainly see in larger organizations that might not be the case.
 

thomas7331

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I am the biller, the coder, the office manager, the legal department, the personal secretary, the everything for my provider. My goal is to keep his butt out of prison, keep his license clear, and keep his practice thriving so I keep my job. That is the type of advice I give him. I can certainly see in larger organizations that might not be the case.
Yes, every organization is going to approach things differently due to different needs. I do work in a large organization and coders are not permitted, in the context of queries on a particular record, to steer providers toward documenting in any particular way. That seems to be the perspective from which the original post was asked. In the context of giving general education on documentation, that is a different matter of course. But as far as I know, there is no law, and no provider has ever gone to prison, because of a requirement that documentation done a week after the service should be considered fraudulent because it is allegedly too long for them to have accurately remembered how much time they spent.
 
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beavert

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Thanks, I just don't like the idea of sending back to the provider advising time needs to be documented in order to bill the code you are submitting. I feel education is the answer and if they still don't do it then that's on them
 
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