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Dr. making his own rules

  1. Default Dr. making his own rules
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    I know of a doc that is making his own guidelines and was wondering just how "bad" this was...
    This doc has been known to change the diagnosis on a OP Note after getting a denial from an insurance company to "get the claim paid" for example the first diagnosis would read:
    **Screening for colon cancer**
    then it would be changed to:
    **Rectal Bleed**
    with no documentation in the op note about a rectal bleed!
    Can someone tell me are you allowed to change your diagnosis codes after the claim has been billed AND denied?
    Where is the definition for this situation? Any help you guys can provide I would greatly appreciate.

  2. #2
    Location
    Columbia, MO
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    No it is extemely unethical to change a dx on an op note from what it was to something completely bogus just for claimpayment. As I have said many times, we must always be 100% correct with the dx code since it is the patient's diagnosis not the physicians.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Cape Girardeau, Missouri
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    80
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    Many docs are now learning how important detail is in their documentation. If there was actually rectal bleeding that caused the reason for the screening, but the doc left it out and then later realized that the claim would be denied without further detail, wouldn't it just be part of the working of the denial for him to correct or add to the op notes if there was actual bleeding, but he just failed to write it up that way initially? Upon denial, couldn't the coder quiz the doc to see if there was info left out to help him to learn to be more detailed?
    I am certified, but do not have actual world coding experience and am still learning. Would appreciate further discussion on this topic.
    ObCoder MA,BS,CPC

  4. #4
    Default
    I learned a while ago not to quiz or question my Dr's about their dx's or lack there of.
    They are busy and have little time to review things like this. The level of education presented by the front office staff is not of much help either.
    So I just simply ask for a copy of the notes. If there is something in there that did not make it to the superbill then all the better. If not, then I have reviewed the notes and will let the Dr know that the claim is not going to be pd the way the visit occurred and any changes from there are on them and not me. I do however require ammended notes before a change is made. I would say that about 70% of the time there is information in the notes that does not make it to the superbill.

  5. #5
    Location
    Charleston, South Carolina
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    641
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    Changing the diagnosis "just to get paid" (especially when its not even documented) is FRAUD!!
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

  6. #6
    Location
    Charleston, WV
    Posts
    245
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    And documenting a condition that did not exist is also fraud.

    If the doc makes a legitimate change to the documentation, the date and time of the change must be documented on the amended note.
    J G Stanley, MHA, CPC

  7. #7
    Location
    Columbia, MO
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    I have always been told that changes such as adding a diagnosis to the note after the fact to get the claim to pay is unethical and potential fraud. The documentation stands as written when the clam leaves the door. A claim can be corrected if more information is found later because it was not reviewed properly upon claim creation. But to allow a provider to amend the documentation once a denial has been submitted? I have always been informed this is a practice that is not allowed.

    Debra A. Mitchell, MSPH, CPC-H

  8. #8
    Location
    North Carolina
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    3,126
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    Quote Originally Posted by mitchellde View Post
    I have always been told that changes such as adding a diagnosis to the note after the fact to get the claim to pay is unethical and potential fraud. The documentation stands as written when the clam leaves the door. A claim can be corrected if more information is found later because it was not reviewed properly upon claim creation. But to allow a provider to amend the documentation once a denial has been submitted? I have always been informed this is a practice that is not allowed.
    Debra,

    I couldn't agree more...

    Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary


    http://www.cignagovernmentservices.c...b0104b08b.html

  9. Default
    Thank you so much for all your wisdom and experience! I was under the same impression but now I have a clearer understanding!

    Thanks again!

  10. #10
    Location
    Cape Girardeau, Missouri
    Posts
    80
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    Yes, thank you for the discussion. So what will billing do with a situation like this? Is the patient then responsible for the unpaid claim? Does the patient pay if the doc makes a documentation error or if he does a procedure w/o documented medical necessity? I realize that patients may sign a paper saying they will be responsible for the bill if the insurance does not pay, but is this their responsibility when the doc makes the error?

    Lisa Gaines, CPC-A
    Last edited by OBcoder2017; 04-01-2011 at 11:24 AM. Reason: didn't put certification level
    ObCoder MA,BS,CPC

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