I mean HPI not PHI, sorry!
During a documentation audit of my providers charts I found "several" instances where the name of the ancillary staff is listed next to the HPI in the patients chart, instead of the actual provider of service.
In investigating, it was determined that two of my providers were under the impressin that when they clicked on to review the chief complaint (or HPI in our EHR), that it changed to the providers name. Our EHR doesn't change the name unless something is added to the record. If the ancillary staff typed in an excellent PHI, then many times the provider didn't change anything and moved on to the ROS.
Here's my question, do we need to audit all medicare claims billed by these two providers and return reimbursement of these services that have incorrect names next to the HPI, to Medicare, or can they do addendums to the charts for these dates of service. My feeling is if their name isn't indicated next to the HPI, then they didn't do it and can't bill as though they did, and we must reimburse Medicare.
Thanks for any of your input on this.
During a documentation audit of my providers charts I found "several" instances where the name of the ancillary staff is listed next to the HPI in the patients chart, instead of the actual provider of service.
In investigating, it was determined that two of my providers were under the impressin that when they clicked on to review the chief complaint (or HPI in our EHR), that it changed to the providers name. Our EHR doesn't change the name unless something is added to the record. If the ancillary staff typed in an excellent PHI, then many times the provider didn't change anything and moved on to the ROS.
Here's my question, do we need to audit all medicare claims billed by these two providers and return reimbursement of these services that have incorrect names next to the HPI, to Medicare, or can they do addendums to the charts for these dates of service. My feeling is if their name isn't indicated next to the HPI, then they didn't do it and can't bill as though they did, and we must reimburse Medicare.
Thanks for any of your input on this.
Last edited: