Coding and billing from incomplete records


New York, NY
Best answers
I am questioning the legality and ethical propriety of coding and billing medical procedures from the doctor's handwritten notes on the patient's hospital facesheet. In this situation, the doctor is recording the date, the procedure and Dx description for hospital inpatients on the patient's hospital facesheet. I do knot know if that these handwritten notations ever make it into the patient's MR; there is no signature on it. I believe it is unethical to code and bill from records that are not part of the legal patient MR. There are no notes of what was performed other than a couple of words such as "initial hospital E&M, level 3", "cystourethroscopy-Bx" or "cystourethroscopy with calculus removal". I wanted to ask for the community's feedback as to their professional opinion if this billing practice is proper. What minimum level of official records are required for me to code and bill from?

Also, if I am coding and billing for a private doctor who does procedures on hospital inpatients and I don't have access to the hospital EMR, what minimum level of record is needed for me to bill for the doctor? If I can gain access to the hospital EMR, can this substitute for the phsician's own practice EMR?