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STR question regarding E/M documentation

  1. Question STRANGE question regarding E/M documentation
    Medical Coding Books
    Doing some audits I stumbled upon something strange and I need some backup.

    A gastroenterologist in our practice saw a patient in our office on 3/30. This patient was scheduled for a colonoscopy (hospital outpatient) and our doctor dictated, at the hospital (to avoid transcription costs here), a pre-op history and exam note that says at the top:

    Date Transcribed: 3/30/10
    Date of Service:4/08/10.

    I randomly chose to do an audit on the office visit for 3/30/10. Because the above note, transcribed at the hospital does not have a DATE OF SERVICE of 3/30/10, I failed him for this audit. After much discussion I was told that I was wrong, that there was no way that he shouldn't be able to use this note because it was transcribed on 3/30/10. As much as I would actually LIKE to be wrong this time, I really don't think that I am. Am I misguided here? Of course i'm going to be required to prove my point, but I would think that if an auditor does not find a note with the correct date of service listed that this would be a big problem. Any advise appreciated!

    Thank you,
    Last edited by jennyannk73; 04-20-2010 at 01:17 PM.

  2. #2
    I don't have anything off hand to show this in writing but you are correct. Transcription date means absolutely nothing other than the service took place some time before it was transcribed. It can not be used as the date of service. This provider needs to amend the note and add the correct date of service in order to be compliant.

    We have recently had many meetings regarding this in my facility (several providers here are using the same argument) our attorney has told them they have to document the date of service and told me not to bill any claims that don't have the proper supporting documentation.

    This is really a common sense thing as well. I have a doctor that is always on the bad list because his dictation is behind. I recently saw him do a discharge 6 months after the actual date of service. Is it ok to use the transcrpition date of 2/15/10 for the date of service when in fact the service was actually 8/20/09? I don't think so.

    Good luck, and if I find my supporting info I will post it. I was thinking AHIMA had a nice document but their site is horrible to search and I don't have time right now.

    Laura, CPC, CPMC, CEMC

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