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PA documentation trumps MD?

  1. #11
    North Carolina
    Medical Coding Books
    Here's the Part B list serve.

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  2. #12
    Default Missing the forrest for the trees I think...
    This is not a coding issue at all in my opinion. This is a quality of care issue. This needs to be taken to the quality or risk management department, the patient record needs to be corrected to reflect what is actually present or not, then you will know what you can or can't code.

    Good luck

    Laura, CPC, CPMA, CEMC

  3. Default
    I agree but that wasn't the question.

    Regardless of the outcome of the review, the MD can not change the documentation by the PA and change her DX. The MD was not there with the patient.

    The MD can (as I suggested) add an addendum to the chart. But regardless of what the MD saw on the films or what the PA concluded on exam, the Radiologist's final report over-rides them both.

    I still stand by that the PA must document and code based on her own assessment. The MD has recourse options of his own he can take. And if there is question to the Rad final report, then a 2nd read by another Rad can be done.

    In the end, after everyone involved has hashed it out and the the smoke settles, a report can be added to the chart if the PA assessment is proven incorrect. If so, then I would re-code the encounter in the system and refile with the correct DX codes to the payer. Not for payment but so that the "big system in the sky" has the correct conditions for this patient.

  4. #14
    Wenatchee Washington.
    Thank you all very much for your input!

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