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Chart audit disagreement

  1. #1
    Watertown New York
    Unhappy Chart audit disagreement
    Medical Coding Books
    Our compliance team has done a random audit of charts in our clinic. They have found that a few charts have a dictated note with a diagnosis of say for example of bronchitis but the physician wrote upper respiratory infection on the superbill. The encounter was coded as bronchitis as it was in the typed dictation. The compliance team feels that the two should be the same and want it brought back to the physician to write the same dx on the superbill. I was under the assumption that the superbill was not considered part of the chart and you should be coding from the dictated note. Please help!

  2. #2
    Louisville, KY

    Have a look at almost any medical record or documentation quality text book and it will say that the superbill (or anything similar or related) is not considered part of the health record. That being the case, the coder is to follow what is stated in/on the record; the superbill really carries no meaning whatsoever when it relates to coding and supporting a claim.

  3. #3
    Watertown New York
    Thanks so much for the confirmation.

  4. #4
    Rochester NY
    I agree. The coder should be using the chart to code, not the superbill.

    Doctors are not coders and they often miss things. Not saying it's intentional, they are just busy.
    COding should be left for the coders!
    A. Judd

    2013 President, Flower City Professional Coders
    2012 Vice President, Flower City Coders local Chapter
    2011 Member Development Officer, local chapter

    "You cannot truly listen to anyone and do anything else at the same time." M. Scott Peck

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