Wiki Chart audit disagreement

[Nancy Grisanti]

Our compliance team has done a random audit of charts in our clinic. They have found that a few charts have a dictated note with a diagnosis of say for example of bronchitis but the physician wrote upper respiratory infection on the superbill. The encounter was coded as bronchitis as it was in the typed dictation. The compliance team feels that the two should be the same and want it brought back to the physician to write the same dx on the superbill. I was under the assumption that the superbill was not considered part of the chart and you should be coding from the dictated note. Please help!

 

[kevbshields]

Nancy:

Have a look at almost any medical record or documentation quality text book and it will say that the superbill (or anything similar or related) is not considered part of the health record. That being the case, the coder is to follow what is stated in/on the record; the superbill really carries no meaning whatsoever when it relates to coding and supporting a claim.

 

[Nancy Grisanti]

Thanks so much for the confirmation.

 

[ajudd]

I agree. The coder should be using the chart to code, not the superbill.

Doctors are not coders and they often miss things. Not saying it's intentional, they are just busy.
COding should be left for the coders!