Wiki Coding without documentation

[carol52]

My office administrator just ask me at what level would I be comfortable with billing out charges without documentation .

 

[TonyaMichelle]

Give the billing company the CMS guidelines for fraud because if they are coding procedures and/or diagnoses without documentation and it just happen to be overcoded indicating maximizing of payments, you as the professional coder can be held liable for inadvertantly committing fraud. The Office of Inspector General has documentation on there website that states that it is against federal rules and regulations to code without documentation. As a professional coder it is mandatory to review the documentation for medical necessity for different procedures and also to make sure each physician documentation is without omissions of significant information on the patient's records because if the documentation is incomplete, that can compromise the patient's quality of care.

 

[DocAssist]

Tony, that is great advise. Carol, it's as simple as, if it is not documented it did not happen. Tony is correct in her statement and I would advise you follow that rule to the strictest level.

 

[carol52]

I knew that this was the case, just wanted to hear this from a reliable source, I have refused to bill out without documentation, I may not have a job if the administrator does not allow me to continue this way. Thanks for everyone's answers I feel much better.

 

[RebeccaWoodward*]

I knew that this was the case, just wanted to hear this from a reliable source, I have refused to bill out without documentation, I may not have a job if the administrator does not allow me to continue this way. Thanks for everyone's answers I feel much better.

Carol,

I would let them read the OIG's recommendation on a compliance plan...

Of note:

The practice’s self-audits can be used to determine whether:
• Bills are accurately coded and accurately reflect the services provided (as documented in the medical records)

This refers to auditing but by coding from the record, you're basically complying with this recommendation on the forefront

http://oig.hhs.gov/authorities/docs/physician.pdf