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documentation compliance

  1. Default documentation compliance
    Medical Coding Books
    Our organization implemented EMR beginning in December 2008. We have 7 sites and implemnted each individually. It has recently come to my attention, through an in-house audit, that multiple(and I mean MULTIPLE) in-house testing, such as UA's, strep screens, flu screens, were ordered and charged out, however, the results were NOT recorded in the EMR. I am not sure how to rectify this blunder. We obviously cannot recall the results of all these tests a year later. Can we place documentation in the chart with current date that states" results not documented"? Suggestions will be greatly appreciated.
    Last edited by jcgiordano; 02-26-2010 at 07:37 AM.

  2. #2
    Location
    Idaho Falls, Idaho
    Posts
    197
    Unhappy
    The Coding Golden Rule is "Not documentated, not done." In order to remain in compliance, you will have to void the charges and send corrected claims.

    Sorry!!!
    Tesja Erickson, CPC, CPMA COBGC, CEMC
    The Coding Surgeon
    Medical Documentation & Coding Consultant
    codingsurgeon@tesja.com
    2012 AAPC Idaho Falls Chapter President
    2011 AAPC Idaho Falls Chapter President-Elect

  3. Default
    I am well aware of that 'golden rule', however, the ordering of the test IS the documentation that the testing was done, but the outcome of the test is not documented. I am not trying to be argumentative, just trying to clean up a mess

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    But with no results documented there is no proof that the test ordered was in fact completed. So I agree we must assume it was not done.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    If this is an order in the EMR system, don't jump to conclusions and say that it was done some orders are put into the system by mistake and were never taken off nor have not expired yet.
    Verify with the provider if the procedure was performed and have it documented in the patient's chart.

  6. #6
    Default
    Does your EMR have the capability of accepting scanned paper items? If the results are available on paper, they could then be scanned into the appropriate records, no?

  7. Default
    The order is the 'want' to have a service provided; the results is the 'satisfaction' of that 'want'. You require both to bill for the service. My answer would be to either get the results into the record or credit the charge.

  8. #8
    Location
    Columbia, MO
    Posts
    12,531
    Default
    Quote Originally Posted by Kbl57 View Post
    The order is the 'want' to have a service provided; the results is the 'satisfaction' of that 'want'. You require both to bill for the service. My answer would be to either get the results into the record or credit the charge.
    I like the way you stated that!

    Debra A. Mitchell, MSPH, CPC-H

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