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Medical record and coding record

ateasley

Contributor
Messages
10
Best answers
0
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.
 

terridiaz

Guest
Messages
106
Best answers
0
As a coder you can't bill out for a service that isn't completed. All visits must be signed off on by the physician before you can bill them out. If they are signed off on but certain parts of the exam aren't documented then you have to make sure you are billing the appropriate level (if you disagree with what the physician has billed then you would need to give it back to them to correct). Also I was looking into the time frame that a physician has to complete dictation. I had the same problem with a physician taking 3 to 8 months to complete dictation and sign off. I was trying to make the point of how does a physician remember exactly what he did for a patient 3 to 8 months later???? Hope this helps...
 
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