Need Help ASAP: Misspelled name a compliance issue?

hmlsmith

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Please help...
I have a surgeon that has continued for months to inaccurately document the name of the assist at surgery.
Documentation consists of only the last name (which is not an uncommon name), spelled incorrectly.
Instead of correcting the documentation, I am getting push back to just bill it out as it is. Also this is not an occasional occurrence, it is pretty much every time this person is the assist.

Is this a compliance issue? Is anyone aware of documentation that states if this can or cannot be billed?
Thanks!
 

Orthocoderpgu

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As coders our job is to make sure everything (office visit/surgery) is documented correctly. Anything not correctly documented can be a compliance issue. I would never bill out the assist with just the last name documented. And the fact that the last name is also misspelled is an issue. This leaves it open to interpretation as to who actually assisted. Not only that, but the surgeon also needs to document that the assist was medically necessary and the specific help that they provided. Just listing the assistants name in not sufficient.
 
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SharonCollachi

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Is he typing it? Is he dictating? Can someone write him a shortcut so all he has to do is typing something like /JC which would then insert the assistant's entire name?
 

thomas7331

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It would be best, of course, if the name was spelled correctly - accurate documentation is important - but keep things in perspective here. Serious compliance issues are those that involve errors that can result in improper payments, violations of law, and/or potentially cause adverse outcomes to patient care. Does a misspelled assistant's name rise to this level? Usually not. If the surgery took place in a facility OR, the assistant's name should be recorded in the OR log as well as in the anesthesia record, in the event that there was a question about who actually this person actually was and unless there two people in this same practice with very similar names that might make this questionable, I think the likelihood of a 'compliance issue' is rather low in this situation. Payers and auditors and law enforcement officials have a lot more pressing things to do than make a fuss over a misspelled name.

Even so, such a simple thing to fix. I would just keep pushing them to make the correction - sooner or later the squeaky wheel will get the grease.
 
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