Wiki Elective ultrasound documentation requirements

[jhanmer83]

When billing a patient for an elective ultrasound (2D, 4D, or gender) that doesn't get billed to insurance, are the documentation requirements the same as for other medically necessary ultrasounds that do get billed to insurance? I'm being told to bill a patient based solely on a signed consent that doesn't specify the type of ultrasound being performed and I'm not ok with billing for a service with no documentation proving the service was provided. Are there any resources that I can provide to my employer that outlines the requirements when it's not being billed to insurance? This has me concerned about compliance and coding/billing ethics.

 

[jkyles]

Hi there, I agree that is a bad idea and recommend reviewing the provider's medical malpractice policy for language on documenting services. Performing any service without documenting it creates a huge liability risk for the provider that in my opinion isn't worth whatever time they save by not writing a note.

Now, as to whether the note must cross all the is and dot all the ts for the equivalent billed service: my thought is that would be easier than keeping track of whether the service is covered by insurance or paid out of pocket. But again, start with the med mal policy.