Wiki Procedure Coding

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mhcpc

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Do any of you have administrators insisting that you code from "belly sheets" (a diagram of a stomach, colon, or biliary tract) instead of waiting for an operative report so all of the charges could be put in by the end of the month? She actually got 2 attorneys who deal with audits to agree to this.
 
Interesting because CMS has very specific documentation guidelines in their condition of coverage final rule. Posting from a "belly sheet" might be acceptable in order to get charges posted for month-end. However, I'd wouldn't send a claim based on that type of documentation. There is no excuse for filing a claim with incorrect information and that is what this could lead to. A false claim is a false claim, no two ways about it.
 
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