Progress Notes

dklepper

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Hi, I am currently a CRC coder and part of my job along with chart reviews is to re-write progress notes and to do addendums for the providers. I am not a clinician but my company requires us to re write plan of cares. We also have to mention stuff that was not mentioned. Example would be “continue to monitor salt intake”, “reduce sedative from whole pill to half of a pill” for sedative dependence, even though not mentioned and even though the provider did not specifically state that anywhere on the date of service or any other date of service. We are also told to use plan of care from previous visits to use for another date of service. I really don’t feel this is legal as a coder. Again, I am not a clinician and did not have a face to face encounter with the patient. My boss says that it’s okay to do this as long as the provider signs the notes and adds it to his chart. Is this legally okay? Please help.
 

TThivierge

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Progress Notes Completion

Hi
This sounds fishy to me....what doctor or NP or PA is going to let you complete his or her progress notes unless he is immigrant and is not good with English language. That can t be right because most alien residents physicians are made to do English/grammar test before can practice here. I'd get more information .Are you working as remote coder?

Lady T
 

mitchellde

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Once you do this you taint the validity of all the information in not only that document but all the chart notes written. It does not matter that the provider signs it. The provider in the room with the patient is the only one that can make notes and addendums in the patient chart. A nurse can add a nursing note but they cannot make a change or addendum to a physician note. How do you even know what to add, and to what end purpose? are you trying to get a higher level of E&M? are you trying to get a diagnosis that will get a service paid? you do understand how really wrong that is. Once a provider is done with a note they are done. When I read a note, if the story does not make sense, like the pregnant woman who had a hysterectomy, then I send the note back to the provider. If the note appears incomplete, such as no plan of care, then I send it back to the provider. In one case the provider could not even remember seeing the patient 2 days later and had no idea what was done. in the other case the provider could not remember if his patient was pregnant. My point being, if the provider that was with the patient cannot recall major issues, then how can the coder be expected to "create" pieces of the even they were not present for. How do you know they were to reduce from a half to a whole pill?
What company would have a coder do this? I think you should speak with a compliance officer and possibly an attorney .
 

pscanlan

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As the others have stated, you are not a medical provider. You should not be editing progress notes in any fashion. This is a serious issue that could have very serious repercussions. I would speak to a lawyer. Then I would speak to a compliance officer. Probably in that order. Your first responsibility is to yourself, not your company. Your company is inducing you to break at the very least common regulatory practice, if not the law. Well it's fraud, right? So yeah, breaking the law too.

Do not feel any loyalty towards a company that would ask you to do this. Any coding company worth it's salt has a process to return incomplete cases to the provider for clarification. Having the coder do this is just wrong.
 

dklepper

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Once you do this you taint the validity of all the information in not only that document but all the chart notes written. It does not matter that the provider signs it. The provider in the room with the patient is the only one that can make notes and addendums in the patient chart. A nurse can add a nursing note but they cannot make a change or addendum to a physician note. How do you even know what to add, and to what end purpose? are you trying to get a higher level of E&M? are you trying to get a diagnosis that will get a service paid? you do understand how really wrong that is. Once a provider is done with a note they are done. When I read a note, if the story does not make sense, like the pregnant woman who had a hysterectomy, then I send the note back to the provider. If the note appears incomplete, such as no plan of care, then I send it back to the provider. In one case the provider could not even remember seeing the patient 2 days later and had no idea what was done. in the other case the provider could not remember if his patient was pregnant. My point being, if the provider that was with the patient cannot recall major issues, then how can the coder be expected to "create" pieces of the even they were not present for. How do you know they were to reduce from a half to a whole pill?
What company would have a coder do this? I think you should speak with a compliance officer and possibly an attorney .
I totally agree. We are doing retro chart reviews for possible HCC capture. We have to link all the possible codes in a new progress note and add the new plan of care to the note. I then have to fax the form to the provider so he can sign it and add to his chart as an addendum. Once signed, we are told that we have to add those missing HCC's to the claims data
since we linked it in our new progress note. That are now linked in our new progress note. I feel like if I mention to her that this is illegal, I will get fired. If RN notes are not acceptable for HCC caputre, how can a coders addendum or progress note be acceptable? Also the compliance officer is under my boss. My boss is an NP, so she is clinical. So her mind frame is clinical.
 

dklepper

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As the others have stated, you are not a medical provider. You should not be editing progress notes in any fashion. This is a serious issue that could have very serious repercussions. I would speak to a lawyer. Then I would speak to a compliance officer. Probably in that order. Your first responsibility is to yourself, not your company. Your company is inducing you to break at the very least common regulatory practice, if not the law. Well it's fraud, right? So yeah, breaking the law too.

Do not feel any loyalty towards a company that would ask you to do this. Any coding company worth it's salt has a process to return incomplete cases to the provider for clarification. Having the coder do this is just wrong.
I agree. My boss is a NP so her thinking is clinical. She also stated that if the provider does not agree with what I have for the plan of care, then the provider can cross it out and change it. I don't even think I can SUGGEST a plan of care. One of my coworkers feels she is safe because she is putting "possible/sample progress notes". Once the provider signs the form, they want us to add the missing HCC codes.
 

pscanlan

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I totally agree. We are doing retro chart reviews for possible HCC capture. We have to link all the possible codes in a new progress note and add the new plan of care to the note. I then have to fax the form to the provider so he can sign it and add to his chart as an addendum. Once signed, we are told that we have to add those missing HCC's to the claims data
since we linked it in our new progress note. That are now linked in our new progress note. I feel like if I mention to her that this is illegal, I will get fired. If RN notes are not acceptable for HCC caputre, how can a coders addendum or progress note be acceptable? Also the compliance officer is under my boss. My boss is an NP, so she is clinical. So her mind frame is clinical.
Wait, your compliance officer signed off on this?!? Red flag, red flag. Danger Will Robinson. Exitus reliquit scaena ante omnis exit in carcerum!

Nothing about this is compliant. Not the sign off, not the "possible/sample progress note" and certainly not adding codes that you yourself suggested be included in the progress note.
 

mitchellde

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wait , what? this is retro review? so these notes are done and the claim sent and paid? and now months after the fact you are to "create" a chart note addendum that says hey wait I the physician meant to also add this this and this and the patient is to do this and that? And your expectation is the physician will read this and sign it or make changes and sign it??? Not even a little bit cool! The Medicare integrity manual for 2018 states that
documentation should be generated at the time of service or shortly after . Delayed entries of 24 to 48 hours after the encounter are acceptable for the purpose of clarification and the addition of information not available at the time of the visit. Anything beyond 48 hours could be considered unreasonable. It is not reasonable to expect that a provider would recall the specifics of a service more than 48 hours after the service was rendered.
To properly execute a medical record addendum the PROVIDER must, at a minimum write the following details in the medical record:
- the date the record is being amended
-the detail of the amended information
-the statement that the entry is an addendum to the medical record
the date the service was amended
-the signature of the PROVIDER WRITING THE ADDENUM.
The medical record should be amended within a reasonable period of time that would allow the provider to recall the specifics. Medical record addendums should be the exception rather than a routine or recurring part of medical record documentation. Failure to properly amend the medical record may give the appearance of falsifying documentation, which is considered fraudulent.


So you see in two different places they clearly identify the author of the addendum as the provider. You should really speak with an authority figure
 

thomas7331

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I always hesitate to pass judgment on a situation without being able to know all of the details, but it certainly sounds to me like a non-compliant situation and I agree with what the others have said. As I see it, there are three main issues here: 1) the plan of care is the responsibility of the provider, not of the coder or non-clinical staff. This is what they're trained and paid to do and I have trouble believing that a provider would even allow this into their patients' charts - most providers I've worked with are not very receptive to non-clinical people making suggestions as to how they should care for their patient. Patients and their plans are paying for this service to be done by a trained clinician, not by ancillary staff. But all that said, you may wish to consider that by asking you to do this, they could also be putting you in the position of violating state laws against practicing medicine without a license. 2) As Debra has explained very well above, under CMS guidelines, this is not a compliant practice for amending medical records. Giving feedback to providers or querying them for clarification is one thing, but 'leading' them to add documentation to previously completed medical records is quite another - the latter is absolutely not compliant. 3) If your boss or employer is giving you the idea that your job could be at risk for speaking up about a legitimate concern raised in good faith, that is considered retaliation which is yet another non-compliant practice, and you are protected by whistleblower laws. Understood, though, that it is not an easy process to have to resort to and this all nonetheless puts you in a difficult position.

I think all of us, to a greater or lesser degree, come across some kinds improprieties in the course of our work in this crazy, dysfunctional US healthcare system. At some point, we all have to decide whether or not those things that we see rise to the level of being a serious enough offense to warrant taking action, and this can take some soul-searching as there can always be consequences. Hopefully you can reach out to your compliance officer or someone else in a position to give you good advice and steer to you a good way to resolve the situation. Perhaps the most important piece of advice is to keep good notes of your discussions and communications, and keep these as a record of when, with whom and what you talked about. Insist on an acknowledgement in writing from whomever you report this to so that there is a clear record that they have registered your concerns and are taking the proper steps to address them. Hope these discussions here are helpful to you through this.
 
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kdlberg

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For risk coding, you are allowed to submit diagnoses that were not originally captured, as long as they are documented in the patient record and addressed at some point during the attestation period, even if the plan was to do nothing, aka "monitor," or another provider is treating the condition. (You would not believe how many doctors I have to fight with to put cardio conditions on there. "But I'm not treating him for it!" It affects your medical decision making, doesn't it? Then code it.)

But we should not be doing anything with clinical documentation.
 
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