ateasley
Contributor
What is the coder/biller liablity in this issue? If you have a provider that has open encounters (non completed vs) from 3 to 8 months ago who goes in and starts completing these records but does not put in a physical exam. Explain: pt comes into the office on 4/3/12 the HPI, Past problem list, Medication history, Allergies, Past surgical, Family, Social history, ROS, and vitals were all competed on 4/3/12. The provider sees the patient that day but does not enter the exam , assessment and plan, and Medical decision making until 7/31/12. The problem is under the phyisical exam he only adds note: not much improvement with persistent weakness. - The provider is coding as a normal office visit.
My problem comes in that my boss wants me to bill them out regards if they are a completed record or not. He does not want me to look at the office note to see if it is completed or not. I argue that it is not a completed record and it is fraud and I can be held as liable as the provider if I bill them as is and then we were audited. He states that it is the providers licenese on the line not me. I need some advice before I take this to a higher level.
My problem comes in that my boss wants me to bill them out regards if they are a completed record or not. He does not want me to look at the office note to see if it is completed or not. I argue that it is not a completed record and it is fraud and I can be held as liable as the provider if I bill them as is and then we were audited. He states that it is the providers licenese on the line not me. I need some advice before I take this to a higher level.