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Documentation to Support Ortho Inpatient F/U?

  1. #1
    Default Documentation to Support Ortho Inpatient F/U?
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    Hello! I desperately hope someone can help! I code for an orthopaedic surgeons' office and frequently get inpatient consults to charge which I'm familiar with and I receive a copy of the dictation of. However, we have some docs who do their own coding and will submit to me a sheet with the initial inpatient visit and then anywhere from 1 to 3 additional codes for follow-up visits. When I asked for documentation of the follow-ups, the surgeons told me "it's in the patient's hospital chart; just go ahead and bill using the codes I gave you." This makes me very uneasy because I can't see anything in writing to support the code they are giving me (we are not EMR so I can't see anything on the hospital side). I can't find anything official in writing on the documentation requirements for follow-up visit billing on our end of it (the office). Does anyone know anything about this? Can I go ahead and just bill, trusting that whatever the surgeon documented in the patient's inpatient chart will suffice? I really don't know where to go with this and obviously don't want to miss any charges, but at the same time I don't want to bill fraudulently, of course. ANY INFO would be greatly appreciated!!!!

  2. #2
    Milwaukee WI
    Default Make friends with Medical Records
    You will need to request a copy of the records specific to your doctors from the hospital.

    I can view the EMR for our surgeons when they see a patient HERE. But when they go to another hospital to see a baby, I have to request the notes from that hospital's medical records team. They usually fax them to me within a day.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Request the medical records from the hospital. Ask for all notes, including hand written notes. Usually the subsequent/follow up visits from my docs are always handwritten notes and only rarely a dictated note.

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