Wiki Legal issues

[michaelloss]

We are having a friendly discussion in the office about legality of filling in charge tickets for surgeries on what physician has coded, even without the operative record. Some contend it is inappropriated, others believe the physician is taking full responsibility and a coder is not liable.

What say you?

 

[mitchellde]

The coder is liable if they put the code on the claim. I would not do this ever. I always code from documentation only.

 

[nc_coder]

Do you know where I can find something stating that the coder is held responsible? I have had this discussion with a former office manager a couple of times. And I reiterated my opinion on it when I became the coding supervisor because I am ultimately responsible for everything my coders do. Currently we are coding from charge sheets that the doctor fills out. They don't actually code the procedure. They just write the name of what they did..."leg wound exploration with evacuation of hematoma". We are not required to have the op note to code this. The office manager says the doctor would be responsible because he wrote it on the charge slip.

Comments???

 

[michaelloss]

I too would like that documentation. I remember something from the CPC classes but will need to check the training book. What I would really like is a legal opinion. We code from op reports but sometimes there is an attempt to shortcut the process and do it on basis of what physician has coded.

 

[mitchellde]

There were several articles in the Coding Edge a few yeaw years back on this very issue. Perhaps you could do a search for these or query the AAPC Coding edge staff. They were excellent articles and there were probably 4 different issues.