Wiki Chiro provider does not document chart notes...

[sempson]

I am a certified coder working for a billing company that does the billing for a chiropractor office. This provider see's 75 patients a day! She is the only provider for this clinic. I do not see any chart notes for these visits in the EHR and when I need medical records to send to an insurance company the notes she emails to me are sign off on the day I receive them and are the only charts in that patients record. I see no other medical notes in the member’s chart. My question is can we be billing insurances like Medicare with no chart notes?

 

[Orthocoderpgu]

It sounds like the provider just keeps track of the patient's diagnosis and modalities on a score card basically and creates the documentation when needed. If I worked at an insurance company I would be leery of any documentation that was authenticated well after the date of service and just before it sent in. I would also be suspicious of seeing 75 patient's a day. That would mean seeing a patient every 6.4 minutes in an eight hour day. Part of a coders job is to make sure that the medical documentation is complete and authenticated before billing, but in this case I'm sure there is no coder and you are working as a biller.

 

[SharonCollachi]

That. What Orthocoderpgu said. But I would also dump the client.

 

[sempson]

It sounds like the provider just keeps track of the patient's diagnosis and modalities on a score card basically and creates the documentation when needed. If I worked at an insurance company I would be leery of any documentation that was authenticated well after the date of service and just before it sent in. I would also be suspicious of seeing 75 patient's a day. That would mean seeing a patient every 6.4 minutes in an eight hour day. Part of a coders job is to make sure that the medical documentation is complete and authenticated before billing, but in this case I'm sure there is no coder and you are working as a biller.

Thank you for your reply. I am working only as their biller and this scares me.