Hello everyone,
I hope that someone can assist me with my questions and maybe a link to supporting documentation.
Throughout my 14 years of coding, I've had the understood that a physician must dictate his ?Date of Service? and sign the dictated operative report. Without these two items, it is considered a non-billable service. So, my question...
1.) if a physician signs the op report and does not dictate the ?Date of Service? but an administrative director or coding director writes the "Date of Service" on the report after verifying it against the OR log/schedule and applying his/her initials stating ?per OR log" is that op report than considered a legal, billable document.
2.) When is it legal for management & others to insert, write and/or apply a "Date of Service" to an Op report on behalf of the physician?
Thank you in advance for your assistance.
Gee
I hope that someone can assist me with my questions and maybe a link to supporting documentation.
Throughout my 14 years of coding, I've had the understood that a physician must dictate his ?Date of Service? and sign the dictated operative report. Without these two items, it is considered a non-billable service. So, my question...
1.) if a physician signs the op report and does not dictate the ?Date of Service? but an administrative director or coding director writes the "Date of Service" on the report after verifying it against the OR log/schedule and applying his/her initials stating ?per OR log" is that op report than considered a legal, billable document.
2.) When is it legal for management & others to insert, write and/or apply a "Date of Service" to an Op report on behalf of the physician?
Thank you in advance for your assistance.
Gee