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Coding without progress note or chart

  1. #1
    Question Coding without progress note or chart
    Medical Coding Books
    I am one of two coders currently working for a group of urologists, I've only been here a month. We are expected to code without progress notes or a chart. The physicians and the NP and PA do their own E&M coding which is consistenly wrong. I was hired to audit their charts but sometimes am expected to "code" from the fee tickets. I am NOT comfortable doing this and usually end up pulling the chart to read the documentation, it rarely supports the level being billed. I have twice brought up the fact that we are coding blind but they will not change anything at this point. My question; is this acceptable? We as the CPC's are required to initial whatever we code. I've always had at least a copy of the progress note attached. If Medicare came in and did an audit, who will ultimately be responsible for the coding?

  2. #2
    Northeast Kansas (NEKAAPC)

    If you are reviewing the fee ticket for correct codes, you do not need the documentation. However, if you have been given the responsibility to audit the service performed, this cannot be accomplished without the documentation. I would ask for clear instruction on your employers expectation for you. I personally would not be comfortable in the situation you are suggesting you are in.
    Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC
    AAPC Fellow
    AAPC ICD-10-CM/PCS Training Expert

    Kindness is contagious-PASS IT ON!

  3. #3
    Columbia, MO
    I disagree with reviewing the fee ticket and no documentation. It is impossible to know from the fee ticket if the codes chosen are correct or not. So many time the fee ticket is completely wrong. The documetation will be the supporting factor in the the choice of codes. Many time the person selecting the codes on the fee ticket is completely uninformed on the guidelines and incorrect choices are made. This occurs with the dx most often and it is so important that we have this correct. Things I have observed:
    The fee ticket shows 314.0
    documentation supports 799.51
    the fee ticket shows 717.15 with 250.00
    documetation supports 250.83 with 717.15
    the fee ticket shows 805.08
    documentation supports 338.21 with 905.1
    I could give hundres upon thousands of examples of incorrect dx codes alone and then there are CPT code issues as well.
    There is no substitute for examining the documentation before codes are submitted.
    There I respectfully disagree with the above response.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    I would disagree also. There is no way I would code without documentation. It leaves too much to chance.

  5. Default
    keep in mind the saying "if it is not documented, it didn't happen"

    if your office is audited they will want to see documentation and if your codes do not reflect the documentation how will you support your coding

  6. #6
    Columbia, MO
    why not review the documentation before coding? If after the fact it is discovered that the codes do not reflect the documentation then you have submitted an incorrect claim. This is Bad.

    Debra A. Mitchell, MSPH, CPC-H

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