Hi,
We will use a dictated consult letter to charge for office visits. A lot of the time when the doctor dictates these he/she will not state the actual date that the patient was seen. Transcription is entering the date of the letter with the date of dictation. By the time we see these in the coding department it has been mailed out to the requesting doctor and to any other doctors providing care, plus electronically signed by the attending. We used to send these back to the MD for an addendum to list the date that the patient was seen so that could be billed for the correct date of service.
Now the policy has changed and medical records is just going in and changing the date of the letter to match the date of service. This is after it has been mailed out to the other providers. We have been told that the "header" information on the letters can be corrected by medical records and that the date of the letter is part of the "header".
Have the guidelines changed? Or isn't this altering the record and should still be corrected with an addendum even if the transcription department just typed in the date instead of the provider. On the coder side of looking at the document we can't see an addendum written by medical records stating that they have changed the document but maybe there is something on the back side? (we can see addendums when they are added by the provider at the bottom)
Our supervisor states that this policy has been ok'd by medical records and by someone in compliance but there are a few of us coders that feel uncomfortable with this. Any opinions?
Thanks for your help!
We will use a dictated consult letter to charge for office visits. A lot of the time when the doctor dictates these he/she will not state the actual date that the patient was seen. Transcription is entering the date of the letter with the date of dictation. By the time we see these in the coding department it has been mailed out to the requesting doctor and to any other doctors providing care, plus electronically signed by the attending. We used to send these back to the MD for an addendum to list the date that the patient was seen so that could be billed for the correct date of service.
Now the policy has changed and medical records is just going in and changing the date of the letter to match the date of service. This is after it has been mailed out to the other providers. We have been told that the "header" information on the letters can be corrected by medical records and that the date of the letter is part of the "header".
Have the guidelines changed? Or isn't this altering the record and should still be corrected with an addendum even if the transcription department just typed in the date instead of the provider. On the coder side of looking at the document we can't see an addendum written by medical records stating that they have changed the document but maybe there is something on the back side? (we can see addendums when they are added by the provider at the bottom)
Our supervisor states that this policy has been ok'd by medical records and by someone in compliance but there are a few of us coders that feel uncomfortable with this. Any opinions?
Thanks for your help!