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Attending Notes vs. Chart Dictation

  1. Default Attending Notes vs. Chart Dictation
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    One of my doctors had a claim denied. When preparing the appeal, we noticed that a debridement was not documented.

    When we told him that it needed to be adjusted off as a coding error - he then provided us with his attending notes from the facility. And there is a handwritten blurb there, about this service. He thinks we should use his attending notes to appeal.

    Any thoughts on this, from anyone?

    Thank you,
    Tammy

  2. #2
    Location
    Sioux Falls South Dakota
    Posts
    358
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    Does this handwritten note contain all the information you need, such as patient name, DOB, etc; the DOS; the facility; the description of the procedure, and the doctor's signature? Some facilities do still use handwritten notes, and as long as all needed information is there, and they are legible, they are still documentation.
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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