Wiki Needle Clinic Documentation

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Acton, CA
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Hi, I am working at an FQHC and we have been providing services for needle clinic but a part of that is we have patients he being seen inside an office for 15 min inside our Medical building. To which we are not coding or documenting, not even NC modifier codes. To my understanding, we MUST document and at least code even if its not to be billed to the patient it still must be documented, please add any clarification that's needed, thank you


company does not want to charge these patients money and they dont have any insurance. My solution is we add the NC modifier and set to self pay so they do not hold obligation for the service, but still bill it out the door so
A. We are documenting for audits
B. We are continue the cycle even if we understand we aren’t going to get paid for it
C. Holding correct diagnostic and billing accurate files for the services


please let me know your thoughts, in my opinion if we omit this information( services we are providing) that leaves the community center liable. Please get back to me soon
 
James
Yes better document who did the order ( NP,, PA or MD, DO ) for meds. Nurse should document type and amount of injection& date& time and location given on body where and dx code. This documenting injection is added to support treatment plan. Plus added in patient s record chronologically
I hope this data helps you
Lady T
 
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