chrislyn1977
Networker
Hi everyone
I have a question about documentation and I knew that you guys are always awesome to help.
We do a lot of Hyalgan and Cortizone injections here at our practice. I thought that for every claim we billed out we needed to have an impression listed in the medical record for that date of service. I was under the impression that each dictation should be able to stand alone.
Well I have a physician assist and a doctor here who disagree. They said they were told that if a patient comes in for a re-injection and the diagnosis had already been established in a previous office visit then the only thing they needed to dictate were “reinjection right knee”. I just don't think that's correct. I think they should dictate the impression for every date of service. If there is no impression listed then I would go back and bill with the “sign and symptom” which isn't dictated either if they are just injecting the patient. My defense is this: If an insurance company ends up requesting the medical record for that particular claim and there isn't an impression listed and no sign or symptom we have no cause to be injecting that patient.
I appreciate any help with this issue and if anyone could give me source to site so that I can show these guys the rule I would appreciate it.
Christy Brown, CPC
Johnson City, TN
I have a question about documentation and I knew that you guys are always awesome to help.
We do a lot of Hyalgan and Cortizone injections here at our practice. I thought that for every claim we billed out we needed to have an impression listed in the medical record for that date of service. I was under the impression that each dictation should be able to stand alone.
Well I have a physician assist and a doctor here who disagree. They said they were told that if a patient comes in for a re-injection and the diagnosis had already been established in a previous office visit then the only thing they needed to dictate were “reinjection right knee”. I just don't think that's correct. I think they should dictate the impression for every date of service. If there is no impression listed then I would go back and bill with the “sign and symptom” which isn't dictated either if they are just injecting the patient. My defense is this: If an insurance company ends up requesting the medical record for that particular claim and there isn't an impression listed and no sign or symptom we have no cause to be injecting that patient.
I appreciate any help with this issue and if anyone could give me source to site so that I can show these guys the rule I would appreciate it.
Christy Brown, CPC
Johnson City, TN