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kobrien

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I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

If an audit took place, it would be ME in a sling. not him.

Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?
:confused: :eek:
 
kobrien said:
I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

If an audit took place, it would be ME in a sling. not him.

Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?
:confused: :eek:
Click to expand...

You said "I feel this is wrong because neither an OP note nor a sticker is a legal document" and then "Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR?".
So, do you want to code from OP report or not? If you think OP report is not a legal document the what is the legal document that you want to code from?

Op report should have Pre and Post Op Dx as well as Planned and Performed procedures. I would not get Dx from other notes.
 
An OP note is not legal UNTIL it is signed.
A patient sticker is NEVER a legal and binding document.
As far as compliance goes, I am sure there is a compliance policy that addresses these concerns. Do not know exactly where to find them.
Anybody have any ideas?
 
kobrien said:
I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

If an audit took place, it would be ME in a sling. not him.

Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?
:confused: :eek:
Click to expand...

Not sure if you'll find what you need here, but maybe it will provide some information you'll find useful.

Pg 7 of 9-25-2000 link speaks about documentation. I would review any link that is applicable to your type of setting.

http://www.oig.hhs.gov/compliance/compliance-guidance/index.asp
 
OP Notes are legal docs.

I know that OP notes are legal documents. Stickers and unsigned OP notes are not.
I know that OP notes are coded by themselves as they are a "stand alone" document. If for some reason they are denied, or the insurance company wants documentation, we send only the OP note, not the entire EMR.
What I really need is the documentation that states the above issues regarding OP notes and the validity of signatures.
I have looked on the CMS and Federal Register websites, and cannot find what I need. How do I explain to the doctor that this is a compliance issue if I cannot find any compliance documentation to back me up.
Help!!!
 
caromissunc1 said:
I know that OP notes are legal documents. Stickers and unsigned OP notes are not.
I know that OP notes are coded by themselves as they are a "stand alone" document. If for some reason they are denied, or the insurance company wants documentation, we send only the OP note, not the entire EMR.
What I really need is the documentation that states the above issues regarding OP notes and the validity of signatures.
I have looked on the CMS and Federal Register websites, and cannot find what I need. How do I explain to the doctor that this is a compliance issue if I cannot find any compliance documentation to back me up.
Help!!!
Click to expand...

Begin reading page 33 and see if this is what you're looking for. It provides signature guidelines and a grid that indicates what is and isn't allowed.

http://www.cms.gov/manuals/downloads/pim83c03.pdf
 
"you should do as your instructed"

I hope you find what you need!
Even if you do, I imagine that it won't change his mind.
If all else fails, inform your doc that you dont look good in "county orange".
 
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