As a certified coder and educator I understand I am completely responsible and liable for anything I teach. I am hoping someone can help me with supporting documentation because I am being backed into a corner.
For the past year I have advised a practice that they are billing for services not supported by documentation. I have done everything in my power to stop these charges from going thru, unfortunately I am just one person and the vast majority have gone through incorrectly. Instead of fixing the billing to match the documentation they want me to "educate" the providers on how to document. I have told them what I feel and several others feel would be the easiest and simplest way. The issue is with PA assistant surgeon charges. The only indication that the PA was there is in the header of the op report. I have instructed them they need to document why it was medically necessary and who did what. They way I have instructed them to show who did what is by using terms like I, We, or mention the PA by name when they do something alone.
This is not good enough. They want me to go thru an existing op report for each provider and reword it to support PA involvement and give this to them as an example of how their documentation should look. I have refused to do this for a year now. I keep telling them I don't know who did what and I am not willing to do that because I don't want them saying I told them they had to do their op notes that way. I have given them examples from other providers showing this type of word usage and I think it is a very basic concept to just start your sentence out with I, we or a name instead of just Next or Then.
I feel this is wrong but as I stated I am being backed into a corner. If someone has documentation to support how wrong it is to mock up existing documentation as an example of what would support the billing they want to do I would greatly appreciate it. I keep telling them they are approaching this backwards. They need to document what was done and code based on that, not change documentation to match coding. I don't have a problem helping them improve documentation, I have a problem telling them to improve it in a way to support incorrect coding practices that are already in place.
Thanks
Laura, CPC, CEMC
For the past year I have advised a practice that they are billing for services not supported by documentation. I have done everything in my power to stop these charges from going thru, unfortunately I am just one person and the vast majority have gone through incorrectly. Instead of fixing the billing to match the documentation they want me to "educate" the providers on how to document. I have told them what I feel and several others feel would be the easiest and simplest way. The issue is with PA assistant surgeon charges. The only indication that the PA was there is in the header of the op report. I have instructed them they need to document why it was medically necessary and who did what. They way I have instructed them to show who did what is by using terms like I, We, or mention the PA by name when they do something alone.
This is not good enough. They want me to go thru an existing op report for each provider and reword it to support PA involvement and give this to them as an example of how their documentation should look. I have refused to do this for a year now. I keep telling them I don't know who did what and I am not willing to do that because I don't want them saying I told them they had to do their op notes that way. I have given them examples from other providers showing this type of word usage and I think it is a very basic concept to just start your sentence out with I, we or a name instead of just Next or Then.
I feel this is wrong but as I stated I am being backed into a corner. If someone has documentation to support how wrong it is to mock up existing documentation as an example of what would support the billing they want to do I would greatly appreciate it. I keep telling them they are approaching this backwards. They need to document what was done and code based on that, not change documentation to match coding. I don't have a problem helping them improve documentation, I have a problem telling them to improve it in a way to support incorrect coding practices that are already in place.
Thanks
Laura, CPC, CEMC
I never did it ) needless to say I left there after a year, they kept pushing me to "call the docs" I found a great place and they do things by the book which is how it should be.