Wiki Physician Billing & No Documentation

[JJOHN0312]

I have a doctor that says he does not have to dictate everyday for each encounter done at another facility. Are there any resources that I can give him that will emphasize the importance of dictating notes? I found one publication on CMS website. Any more thoughts?

 

[LouiseR1]

are you talking about written notes vs dictated notes? or making a note all-together? and is this in reference to hospital or SNF visits?

Louise CPC

 

[JJOHN0312]

Doctor says he only has to dictate notes every 3 days. These are hospital encounters. No written or dictated notes.

 

[mitchellde]

if there is no note for the encounter there can be no claim for that encounter. If he sees and writes/dictates a note every third day then you can submit a claim for every third day. If he sees the patient every day but writes/dictates a note for every 3rd day then you can submit a claim for every 3rd day. You can submit a claim only for encounters that have been documented. You must review each note as the coder, even if the provider assigns the level of care you need to verify that the level has been met by medical necessity and documentation. Even the inpatient encounters.

 

[JJOHN0312]

Thank you very much! I also think that this is mandatory for the physician to do but wanted to get some feedback before continuing on.