Coding & 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?
The only legal and ethical issue governing coding is that the codes submitted on the claims have to be supported by the medical record - the laws don't tell organizations how you get to that result, only that you do. So there isn't a regulation to say whether or not coders should or should not bill from handwritten or unsigned notes, only that the resulting claim be accurate. Some organizations may allow this because they trust that physicians are completing their documentation correctly, or they may have quality measures in place to ensure that the process results in accurate claims, while other organizations may require that coders only code from a finalized and signed record - it is the responsibility of your organization to ensure quality through whatever process it implements.

It's understandable to have a level of discomfort with this since as a coder, code choices are supposed to be supported by the medical record and it's impossible to make accurate code choices if you can't see the actual record. If you are coding just from a physician's notations rather than the records themselves, my suggestion would be to find a way to sample some actual final records to get an idea of whether or not your physician's process of communicating to you is resulting in accurate claims. If you find discrepancies between what the physician is giving you and what it is the record, then clearly this system it not working well and should be changed. On the other hand, if your coding is well supported, then it will put your mind at ease. But either way, a regular periodic internal audit of claims against the records is a good idea.

Just an FYI you've posted your question three times on the forum - please, no need to make duplicate posts - most forum users review posts in all sections.
Please see the CMS Signature Guidelines

Hello codeseeker,

If the documentation does not have the providers signature it is not a billable service nor legal document. If your provider was audited and the only documentation for the service was the unsigned facesheets money paid to your provider by insurance would be taken back. Please check out the CMS Signature Guidelines for more information:

I do feel the same as you, even if the notes were signed I would not feel comfortable coding from a facesheet with the information you have provided. Have you spoken to the provider about this yet? If I were you I would mention the signature issue and ask if the provider could obtain the notes from the hospitals EMR system or if there was someone to contact at the hospital to obtain the notes. As long as the provider performs the service,documents properly and signs the notes in the hospital EMR you can code from those.

Hope this helps~