Documentation Help

jamcculley

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Alvord, TX
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I recently started at a new internal medicine practice. I need help locating the data to back me up. My physicians code their own visits. When I get the encounter sheet they have listed diagnosis codes. Sometimes I have to verify something in the EMR so when I go to the EMR, I am finding that the codes are not matching the encounter! Either they will be in a different order or there will be some listed on encounter that are not in record or vice versa. Which ones do I use? All of them? Only the ones in the chart? I'm at a loss. The practice does keep the encounter in storage.

What about if the only place a removal of a skin tag is documented is on the encounter sheet? The chart states that they are there but does not mention their removal, it was just written in on the encounter form.

I need to know where to find the guidelines so that I can prove to them that I know what I'm talking about when this gets brought to their attention.

Also, someone said that we can't bill 80050 to any insurance company because Medicare doesn't cover it and "we must bill everyone the same." I was taught that we could bill differently as long as we billed all "classes" the same, such as bill all BCBS the same, all UHC the same, all MCR the same, all Private Pay the same, etc. I have been searching for documentaton to back me up on this for days and can't seem to find it.

My medicare carrier is Trailblazer.

I would appreciate any help.
 
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