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Wiki How do you handle this in your office?

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LisaAlonso23

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McKinney, TX
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How does your office handle it when they receive incomplete charts from providers?

Some examples:

The start and/or stop time is not on the chart.

There is no diagnosis on the chart.

There are no anesthesia providers listed on the chart.

If the above information is not on the actual chart, but it's on the superbill, do you code it or send it back to the provider to complete the record?

Any input would be appreciated. TIA
 
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It should be returned to the provider for the information, that helps them to be more aware and careful in the future. If it's an unusual situation, then request a copy of the anesthesia record graph for the details.
 
Thank you.

I had a wonderful process in place that demonstrated OIG compliance, but it was dismantled so as not to upset providers. We are no longer permitted to put claims on hold to query providers.
 
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