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Thread: Documentation

  1. #1
    Join Date
    Apr 2007
    Gulf To Bay, Clwtr FL

    Question Documentation

    AAPC: Back to School
    Can someone please clairfy?

    I have a claim that needs documention to support medical necessity.

    Child came in for 4 yr wcc and failed hearing on both ears. We brought back a few weeks later to re-ck the hearing. The doctor only dictated @ the re-ck is "re-check ears" no metion of failing @ 4 yr, nothing else. Child did pass this time. There was other notes for this dos, but not pretaining to the hearing....

    When I addressed this with the doctor, she said "she failed @ the 4 yr and thats why we did it again, refer back to that note."

    I was under the impression that each office note has to be a stand alone note. That for the re-ck it should of stated " re-ck do to failure @ 4 yr wcc on XX-XX-XX. Or something along that line..

    Can I have her add an addendum to her note saying that? I do not think BCBS will accept "re-ck ears" as supporting documentation.

    Thank you!

  2. #2
    Join Date
    Apr 2007
    Bangor, Maine


    I don't think that she can add anything "after the fact" now but maybe let her know that in the future, even documenting what she said about "refer to last documentation" would be better than nothing. Every report does have to stand alone and you are right there. When in doubt, query the physician. If they want to be reimbursed properly, then they should listen to what you have to say about the matter. If only the physicians could see how much proper documentation can help with reimbursement, I'm not sure that they realize just how important it is sometimes!! It can ocasionally come down to only a few sentences or just asking the right questions and documenting them. Only in a perfect world, huh?!

  3. #3
    Join Date
    Apr 2007
    Gulf To Bay, Clwtr FL


    Thanks Leslie, thin kthe Dr will just have to eat this one...

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