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Documentation question

  1. Default Documentation question
    Medical Coding Books
    Ok, this is going to sound awful, but soon after my office switched to EMR, we had a patient seen for a Nexplanon insertion. Somehow, the practitioner did not save the visit correctly and all documentation is gone. We contacted the patient and she confirmed that, yes, we did indeed put the implant in for her on that day. Is there any way that it is still billable or should we just count our losses and move on? Thanks for any/all help!

  2. #2
    Default
    You don't state how old your date of service is, but if it was within the past 30 days or so I would suggest recreating a procedure note. If you have the NDC for the unit, the location of the insertion and your prior authorization (if needed) I think you have what you need to document your service.

  3. Default
    It was within the last few months. Our practitioner wanted to speak with the patient herself (clinic manager was the one who spoke with patient), but she has not been able to reach her. Thank you for your advice.

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