Wiki need help finding article

[LuckyLily]

Hello All,

Does anyone know of the exact Coding Clinic or CPT Assistant article that was published sometime in the '90s that addressed it's inappropriate to query the physician when they do not document portions of the progress note like the HPI, Exam, etc...

I've had a coding company reference to this article stating they will not send a query to physicians if they do not document, stating this will be leading the physician to create a higher level of service.

I've moved on to another position and can no longer ask the coding company for this article and I cannot find it. Does anyone else know the article in Coding Clinic so I can reference to it again.

Thank you

 

[gjverhovshek]

need help finding an article

The 1990s are a LONG time ago, in coding years. I'd be very wary of observing any guidelines published that long ago... Chances are good that they've been updated. With that said, can you share anything else you remember about the article? I might be able to help you find it, but I'd need some more information. Please contact me directly: g.john.verhovshek@aapc.com

 

[LuckyLily]

Unfortunately I cannot remember anything else about the article.

Are there any other sources that address the issue of providers not documenting a portion of the progress note (HPI, EXAM) and the coder should not query the provider for documentation. I know that you can only code what is documented, but it is becoming an issue that management wants queries to go back to doctor for the documentation they did not complete.

Thanks for the help.