Coding with no documentation

Messages
2
Best answers
0
I just got my first billing/coding job in a small one physician office. The problem is that the doctor hardly documents anything. Most of the time the doctor doesn't so much as put a note in the system saying that she saw the patient or even check off on the encounter form what she did or what the diagnosis is. Its a specialty office so we see a lot of the same things but the office manager wants me to just pick codes based off of what it says the patient's appointment was about when they were scheduled and the results from labs. I've also been told that asking the doctor to document more or asking too many questions about a case will only get you yelled at. Have any of you had to deal with this? Am I allowed to code visits without any sort of documentation or word from the doctor? Is that considered insurance fraud? If you were in my position what would you do?
 

mitchellde

True Blue
Messages
13,537
Location
Columbia, MO
Best answers
2
The coding guidelines state that without documentation, accurate code assignment cannot be achieved. I would not code anything without the chart note. Also a coder is not allowed to code from Lab results. You may code from radiology interpretations and pathology interpretation.
 

michellepilcher

Networker
Messages
88
Location
Anchorage , AK
Best answers
0
"If you were in my position what would you do?"

I'd look for another position while working this one. If you are discouraged from asking the provider any questions, you'll never be able to do your job, nor will you be happy. And in all reality, if you spend 8+ hours a day somewhere, are you looking to be miserable?

I was hired by a provider pretty much the same way. He was encouraged by his billing service to hire a coder; however, he had no desire to code anything correctly or learn how. It didn't last long. What he wanted done was fraudulent and I
figured I wasn't going down with the ship. Good thing since his entire staff eventually left because they were questioned by the FBI.

You found a job while looking for this one, you will find another. Just because they have run their office in a manner in the past that is unacceptable doesn't mean you have to go along with it. Risking a credential you worked HARD for isn't worth it on any level.
 
Top