correcting documentation before claim submitted

la_0922

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I code hospital billing and I have a provider who has an intern following him, recently he has allowed the student to document handwritten progress notes and he signs over them correcting/adding/ inputting his own MDM, however the note doesn't have anywhere documented that the intern wrote it, it is obvious that it is two separate penmanship's.... I have not billed these visits but after researching have found that if the intern signs it and a statement from the doctor stating his participation etc...the note may be billable..... HOWEVER- I have many concerns....

1) can the document be corrected? even though I haven't billed for the service yet, can he and the intern amend the note? I believe he should for documentation purposes, but for claim filing purposes is this acceptable? if not can someone provide me a link so i can show my provider why this cannot be billed.
2) do he and his intern have to meet some sort of requirements to fall under the "supervising physicians in teaching settings" requirements?

please advise as he will definitely ask these questions.... plus I do need to educate him for future visits...please advise...
thank you,
L R
 

mcpalmeter

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Local Chapter Officer
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Jacksonville, Florida - 90417
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Correcting documentation before claim submitted

The only pieces of a medical student's documentation that be used to support a billable service are the ROS and PFSH. Every author in the medical record must be identified.

Regards,
 
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