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Thread: Coding without a delivery note

  1. #1

    Unhappy Coding without a delivery note

    AAPC: Back to School
    Hello everyone,

    I am just curious as to what others do in a situation when there is no delivery notes for either vaginal or cesearan deliveries?

    We do the coding for a mulitspeciality group. The doctors send over all of their superbills and hospital charges. We have quite an issue with the drs taking over a month to put in op reports and sometimes none putting in at all. This is an on going battle.

    So if they send over the patients face sheet with the delivery code for a vaginal delivery but there is no delivery note in the system. Is it okay to bill with out a delivery note?

    Thanks for any help.

  2. #2


    I would double check with the physician or the hospital for the note. The CMS rule Section 7103.1 (1) indicates that if medical care is not documented in the medical record, it is treated as if it had not been performed. If you do not have documentation to back up the charge you can not bill until you do.

  3. #3
    Join Date
    Apr 2007
    Carmel, New York


    Can you get or obtain records from HIM at the hospital? While not for an OB/GYN practice, I had this same type of issue of trying to obtain notes or records. I was lucky in that the hospital had an EMR, so I was given access to view our doctor's notes. If they are paper notes, is it feasible to see if you can obatin them?

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    I agree no note no codes no claims! If the doc wants to take 2 months or .longer to get a report done then that is how long it will take me to code it.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Join Date
    Apr 2007


    I completely agree with Diana's answer. If you dont have the documentation, you can not bill the service until you do. I believe if you dont have the documentation the service never took place.
    Barbara Liimatta-CPC

  6. #6


    I was always told if there is no documentation then the visit never happened.
    Dr's make mistakes all the time, how are we to know that they did their SB's correctly if there is no documentation to back it up. I look at it this way, if I'm audited and there is no documentation to back up my claims, will the Dr help me pay my bills when I get fired? Probably not!!!!

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