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Documentation to Support Inpatient F/U?

  1. #1
    Question Documentation to Support 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
    Dover Seacoast New Hampshire
    Marie, you have my sympathy.

    Because your docs have priveleges at the hospital, you should have access to the medical records for billing purposes. Contact the director of Medical Information to see how you might be able to work together to get those records. Here at WDH, we have provided our non-employeed providers who have priveleges with access to our electronic medical record so that they can sign off on their charts, but also so that their billing staff can veiw the physician documentation for billing purposes,. They still have the ability to contact the medical records department for hard copies if they are needed. We have this arrangement with several facilities for whom some of our physicians consult. We request the notes and they send them over. You may not be on an EMR, but if the hospital has one, you may be able to have 'view only' access for your patients.

    It's cumbersome, but I'd encourage you to get the documentation in your hand before you bill out the charges, particularly if you're being asked to bill an E&M for a visit within the surgical global need to see the dates and documentation for compliance purposes. Without seeing the actual medical record, in essence, the visit isn't supportable. Sure, the docs say that the documentation exists, but I would remind them that in an audit, you would be required to provide the documentation, and that it better match what you billed. You're also correct in that without the documentation to review, you may be missing out on significant revenue.

    Keep us posted. Pam
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Fayetteville, NC
    In my opinion you are right. I would never bill without seeing the documentation.
    My docs dictate hospital follow-ups in the charts but frequently do not even give me a diagnosis and I routinely have to go to the hospital computer in our office to get those diagnosis. When I do that I print the follow-up notes from the hospital so that we have the documentation in the actual chart.
    If you do not have access to the hospital records via computer maybe you could get them to fax them to you?

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