Wiki No Dicumentation or Incomplete.

[brittndave10]

We are a Pediatric Surgical Practice. Our doctors circle the E/M service they want to bill, but no documentation is provided to us coders to review. We are told by our internal auditor & office manager that it's not required for us to have the documentation, that it's the doctors responsibility for the coding.

Also, when the doctors do surgery, we are receiving documentation that has random blanks through it & isn't signed.

We have both expressed that we needed the documentation to check that the correct level of service is being billed out, and that the surgery documentation needed to be complete & signed.

What do we do if they won't allow us to have the E/M documentation & completed surgery documentation?

 

[mitchellde]

honestly I would not code anything without complete documentation. look at the official coding guidelines in the front of your code book on the first page of the guidelines it states that complete documentation is needed, and the documentation should be reviewed for correct code assignment.