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Important question

  1. #1
    Default Important question
    Medical Coding Books
    Regarding dictatin and documentation.

    If you go to audit a chart or pull up dication in the transcription system, and it's not signed off on yet.

    Can you code off it?

    The reason I ask is at times the physican takes a week or two to sign off on, and I have access to the prelimary dictation reports. But there not sign off on, I'm tempted to code off that.

    Daniel, CPC

  2. #2
    Hi Daniel,
    It has been my experience that physicians do not read their dictations and just sign off on them
    I would just code from the preliminary report was that you are not holding up the bill process
    Hope this helps
    Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC

  3. #3
    North Carolina
    I would encourage you to contact your individual carrier. My carrier...

    "All Medicare providers billing Medicare for service shall ensure that their signature is attached to these documents. Each provider should immediately put into place a protocol to assure these items are signed within a reasonable time frame, usually 48-72 hours after the encounter but certainly before the claim is submitted."

  4. #4
    Hi -

    It has also been my experience, that sometimes the dictation is not always correct and the doctor may change some things in that regarding the procedure or dx and even sometimes the order of the dx. Hope this was helpful.

    Marla K, CPC

  5. #5
    I agree with everything said, but if you had a working realationship with these two doctors that your pulling preliminary dictation on.

    And these physicians told you personally that they never change anything except for minor spelling errors and it's ok to code of the prelims.

    Would you still go ahead.

    Reason being is that the prelimary reports come up in the system with in one day, versus waiting for dication thats been signed off on. Which can take up to 3 days.

    Hopefull I get more opions


  6. #6
    Milwaukee WI
    Default Who dictated?
    If the provider did the dictation him/herself then we will code without the signature.

    If a resident did the dictation we will wait for the teaching physician to review and sign before coding.

    Our hospital system sends a DAILY "delinquent" report reminding physicians to dictate and sign operative reports. Their privileges can be suspended if they fall too far behind.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  7. #7
    I love your hospital policy. Where are you located?

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