Wiki Physician Letter

[Sephardic]

I've got a physician that is trying to bill a 99205. A biller came to me to have me audit the level of service (the insurance is of course denying it). The office visit notes probably won't meet a 99201. There is a letter the doctor wrote to the referring physician the same day of the visit and it actually has much more detailed account of the office visit (like a ROS and a physical exam). I've never run into this situation before but can I use the letter to fill the gaping holes in the office visit notes?

 

[martinni1974]

The clinical documentation cannot be amended by anyone but the authenticating physician/provider. He can amend the documentation himself identifying the date of the amendment.

I work as a fraud investigator/auditor for a large health plan and I can tell you when we request documentation we will not accept the letter that was sent back to the requesting provider to support the E&M billed. We ask for all originals to be sent with any dictated notes/letters. While we will accept a slight variance between an original and a dictated note if the documentation is a conflictive as you state you will need to have him compliantly amend his note.

Good Luck