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Documentation conundrum

  1. #1
    Default Documentation conundrum
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    I have a question that I hope I can get assistance with.

    As I go through a patients progress note the physician will say something like "patient needs B12 injection". It is not documented that the patient actually received the injection in the progress note. When I look in another part of the EHR to see if there is an order for the B12 and it is notated that the patient received it, is that documentation in the separate part of the EHR good enough to add the charge for the B12 or should I send a query and request for the information to be added to the progress note.

    I know the statement 'if it's not documented it wasn't done' but how does that pertain when it is documented somewhere else. I've also seen this situation with immunizations, supplies that are given and certain procedures.

    Thanks for the help

  2. #2
    As long as the procedures you're coding billing are properly documented and you can produce those records in required for an auditor to verify that the services were performed, it does not matter that they are in a separate location in the patient's chart. In fact, with injections and other services that are performed 'incident to', it would be entirely expected to find these in a different location in the record because they will be documented by the ancillary staff who perform them rather than by the physicians themselves.
    Last edited by thomas7331; 08-24-2018 at 12:38 PM.
    Thomas Field, CPC, CEMC

  3. #3
    Default Documentation Question
    Hi Lily,

    Yes if it is not in the medical record it is not supported by a provider's notes you cannot code it. At my last employer the nurse had to document time, their initials, quantity of medication and type of injection plus their name when gave a patient an injection or home office lab test (blood sugar finger stick). Is that the protocol for your site of documentation in the medical records you code? This helps all of us medical coders to ensure we are following medical coding regulations and supported by our ethics.

    Have a great day!

    Lady T.
    Last edited by TThivierge; 09-07-2018 at 03:56 PM.

  4. #4
    Medical Billing
    I wouldn't see an issue with coding it. If the service has documentation you could provide during an audit or if the payer questions the charges, they aren't going to care if the documentation is in two places. If you're submitting records to a payer who doesn't have full access to your records system, and there isn't an indication as to why the B12 is needed in the injection logs, i'd submit the records that show what the physician diagnosed them with to need the injection in the first place, as well as the records that show the injection actually happened. I've worked for a couple regional insurance companies and still work for one today. I've never worked somewhere that would deny a claim based on that reason alone(i mean, it could be an excluded drug, or not covered based on what the diagnosis is, but those are separate issues.)

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