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Thread: Ethic or policy?

  1. #1

    Exclamation Ethic or policy?

    AAPC: Back to School
    I have a situation here where I work that I need others opinion on. I have a manager that says that a biller should be able to go into a document, make edits to that document and then turn around and bill it out. I have a problem with that. I don't think any biller or auditor should be able to go into a document, edit it and then bill it. Yes, there is a trail of who was in the document, so the biller's name would show up as being in the document and editing it.
    I don't think that there is any rule or policy out there stating a biller can't go into a document but I feel it is unethical to do so.
    What do others think about this?

  2. #2
    Join Date
    Apr 2007
    Procedural Coders of Mountain Empire


    Absolutly no way would I let anyone other than the doctor or PA/NP who created the note make any changes to the note. And even if the creator of the note makes changes he or she would need to make amendment to the original document and leave the original alone.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default It depends

    Our system used to allow for "proxy" edits ... yes a trail was left to let you know who was in the document. The only time a proxy ever edited a note was when there was a spelling error or Date of Service correction that could clearly be substantiated (for example DOS on op note is 7-3-09 when date of dictation and anesthesia log both show 7-02-09).

    The system we have now does not allow for proxy editing, so we have to alert the provider to any errors we might see. Only the person who dictated can make corrections.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Join Date
    Apr 2007
    Charlotte, NC


    I agree wholeheartedly (since I believe my heart is still in one piece), with both tessa and April.

    The ONLY time any changes should be made to a document in a medical record is when there is an amendment made by the physician or NP/PA.

  5. #5
    Join Date
    Apr 2007


    I agree as well. I would not touch that with a 10 foot pole! How do you know what was done? Were you in the room? Just seems like you are inviting fraud if you let this happen.

  6. #6


    Thank you all for responding. I knew I wasn't going to touch the document but I wanted to make sure I wasn't alone in this.

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