jamiepeters
Networker
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.
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.