I'm not sure I'm correctly interpreting the scenario but ...
Our coders will occassionaly review documentation - BEFORE actually sending out a claim. These kind of spot check, prospective audits, are NOT true audits. If there is a discrepancy between the level on the encounter form and the documentation, the coder gives the physician the option ... "we can code level X which is documented, or you can amend your documentation to meet the level you chose."
Sometimes it's an oversight ... physicians DO get interrupted mid dictation ...
You are correct, however, that once a service has been coded and billed, and you receive an official audit, then NO, you cannot change your documentation.
Hope that helps.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join