Wiki Interoffice procedure

[j.bedford]

I have just started coding for a OB doctor who does interoffice procedures. He only states that this CPT code was completed with no other documentation. I am having trouble finding information which states the requirements for billing for a procedure. I am pretty sure it comes from Office of Inspector General but just can not locate anything. Can anyone point me in the right direction to find this document? I want to be able to prove to the physician that more documentation is required without sounding like this is my opinion.

 

[j.bedford]

Nobody?

56 views and no one has replied? Is this really that hard of a question?

 

[CodingKing]

Your payers will likely have medical documentation standards in their policies.

 

[thomas7331]

Here is a good resource from the OIG:

https://oig.hhs.gov/compliance/physician-education/roadmap_web_version.pdf

Physician documentation is addressed on page 12. If you do a search on the CMS or OIG web sites you'll find many other instances where it is discussed. But I can't imagine that your physician would challenge you on this - providers are well acquainted with medical record documentation requirements and they would not have made it through medical school if they had failed to document. If these are 'interoffice' procedures, perhaps the documentation is simply housed at the other locations?