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risk management coding

  1. #1
    Default risk management coding
    Medical Coding Books
    I'm new to HCC coding and am responsible for educating physicians regarding issues I find when performing audits. I work for a health plan and when auditing, if there are questions or thoughts that a physician potentially missed a dx or did not document treatment for a dx he coded, the current policy has been to send back to the physician for an opportunity to ammend the record, which does not sit right with me. I know coding rules are standard, but since I am new to this area, I want some other feedback. Can anyone help?

  2. #2
    Columbia, MO
    You mean to amend the record after the claim is sent and all? Then no this canot be done. But for a coder to see that additional documentation is necessary in order to submit a claim, that is perfectly fine. The claim is to match the documentation and then the documetation must support the claim, but it is wrong and potentiallylegally wrong to amend or change documentation after a claim is sent and rejected or paid to then "fix" the documentation to match the claim or support an appeal.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    I am getting conflicting information on whether the claims are submitted at the time of the audit. From what I understood, I thought the were all prior to claim submission. I just wanted to get other feedback on whether others feel it's appropriate send records back to physicians. Ultimately, they are responsible for all their own coding. I believe in educating them so they understand from this point forward......

  4. #4
    North Carolina
    I agree with Debra. Below is CERT's guidance for this...

    Before submission of a claim:

    Delayed entries within a reasonable time frame (24 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.


    After claim is submitted:

    Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.

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