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Physician provided codes/incomplete charts

  1. #1
    Richardson, TX?
    Default Physician provided codes/incomplete charts
    Medical Coding Books
    I have two scenarios I would like some opinions on.

    1. We have physicians who provide codes for us to bill. We do not always see the charts, and sometimes when we have we have found the op note does not match the codes provided but we are told to bill the codes the doc gives. We are a billing company and they say the ultimate responsibility lies with the Dr.

    2. We get superbills or face sheets from some surgeons that have very brief descriptions on them. We cannot always obtain the op note so are told if the op note is not provided to just code the best we can with what we have. In some cases it is not a problem as a lap chole is a lap chole but in some instances there may be multiple possible codes. THis makes me uncomfortable because I am now the one assigning the codes based on the documentation available. In an audit I have to trust they have the proper documentation to support the codes.

    Anyone out there have any experience in dealing with these type situations?



  2. #2
    #1 is an ongoing problem for anyone who codes from a superbill/encounter form. Best case is to code from documentation. We have some docs who do assign the codes. If we are using a superbill/encounter form, we make sure this is signed by the physician and is incorporated into the chart because we have found that the dx do not always match the documentation. If it's unsigned, we don't use it to code from.

    As for #2, I do not code any procedure without a signed procedure/OP note from the physician, ever. If anything is unclear, I send it back to the physician for clarification. I never guess or just code the best you can. That's just asking for trouble.

    Just my opinion.
    Anna Weaver, CPC, CPMA, CEMC
    Associate Auditor

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