Wiki Charting Questions

jamiepeters

Networker
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27
Location
KLAMATH FALLS, OR
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My office recently has a provider asking the coders to add certain things to his chart note and it seems I can't find any good information to present to him why we should not do things the way he is asking.

1) The provider is asking that we add a DME item to his note if he forgot to include it in his signed note. We currently would send him a note asking him to confirm if the item was dispensed and if it was then asking him to add it in his note. The only way the coder would know that the item was dispensed was if it had been marked on the paper fee ticket that was scanned to the patient's chart.

2) The provider is asking the coders to analyze the note then for any items that were deficient he wants us to add a blanket statement to the chart note such as;
"UPDATED PER DR. _______: 4 views of XYZ (cervical or lumbar) spine, Findings PER DR. ______: MULTILEVEL DISC DEGENERATION NOTED. IF THERE ARE ANY OTHER SPECIFIC FINDINGS PRESENT DR. ________ WILL ADD LATER."
To us this would mean that every patient that he didn't document an x-ray on would have Multilevel Disc Degeneration and this would be the code going out on the claim.

Can someone please tell me what the rules and guidelines are regarding these types of situations and if you have the answer can you include a link to where we can find the information. I would greatly appreciate any help in this matter.
 
Stuff like this gives me palpitations. A coder is like a translator. They take the information already there and assign the appropriate codes and modifiers using guidelines. Just like a translator might need to ask whether the original speaker used the word "accept" or "except" if it's not clear in the context, a coder may query a clinician to clarify information. A coder should never be permitted to alter the actual medical records.
In my opinion, once a record is completed and signed, no one other than the clinician should change it, except in rare unusual circumstances by an APPROPRIATE person does, AND the clinician must still re-sign it.
example of acceptable: pt seen 8/22/22. RN took history, note is completed and signed by clinician on 8/22/22. 10 minutes later, RN realizes she forgot to enter the surgical history into the EMR. When she corrects it, the physician must sign again.
If there in anyone at your employer responsible for compliance, that is exactly what this falls under. I would only loop in compliance if the physician is just not getting how incorrect this is.
Here are some references:
From CMS https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c03.pdf :
"Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies."

Good luck!
 
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