Wiki Compliance rule for changing a diagnosis when provider is no longer with the practice

[KLITTLEFIELD]

We have a diagnosis that has been billed as unspecified and it needs to be changed to specified. The note does up hold the specified diagnosis but the provider is no longer with our practice. Does anyone have the guidelines on how this is handled?

 

[JEYCPC]

I would ask the senior doc to review the notes and give you the specific dx. And have him document in the chart and sign it. JMHO

 

[mitchellde]

If the specific diagnosis has already been rendered in the chart note for the encounter then there is no problem. Just use the code for what is documented.

 

[CodingKing]

I would ask the senior doc to review the notes and give you the specific dx. And have him document in the chart and sign it. JMHO

I'm going to agree with mitchellde that if the current documentation supports a specific dx you can change the DX and submit a corrected claim. A senior physician should not be making changes to the Medical record after submitting a claim. That would be a compliance issue, especially a physician who did not treat/evaluate the patient.