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altering Drs progress notes

  1. #1
    Location
    Grants Pass
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    Default altering Drs progress notes
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    I am new to E&M billing, my experience is in billing surgeries from Op reports. I work for a group OB/GYN practice that uses EMR. The EMR system allows the Drs to "click" items in the MDM section-indicating they reviewed or ordered labs, imaging, rx, ect to help the EMR select the level of E&M service for them. Several of our billers, with the OK of the Drs, are opening up the Drs signed progress notes and "fixing" what the Dr neglected to click. They are then billing out the level of E&M the EMR selects. The Drs resign their note at a later date. This seems wrong to me, but I am unable to find anything to back this up. At least, it seems the billing should not take place until the Drs review and resign their progress notes.
    Can anyone offer me any guidance with this?

  2. #2
    Location
    Columbia, MO
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    12,570
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    They are called physician notes for a reason! A biller is never ever to add or subtract information from a physician note regardless of whether he signs it later. The biller has no way to 100% know what items to check. This is not a good practice at all. The provider is the one that makes amendments to his/her own note. If a gap is detected by the coder/biller then the documentation should go back to the provider for amendment.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Kansas City, MO
    Posts
    431
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    Quote Originally Posted by mitchellde View Post
    They are called physician notes for a reason! A biller is never ever to add or subtract information from a physician note regardless of whether he signs it later. The biller has no way to 100% know what items to check. This is not a good practice at all. The provider is the one that makes amendments to his/her own note. If a gap is detected by the coder/biller then the documentation should go back to the provider for amendment.
    Agree 100%!! Any good EMR system will show who made the changes...if not outwardly visable, then maybe behind the scenes...and this could come back to bite you...also if the physician is sharing their password, this is not ok.

    The OIG has a focus this year on the EMR...check out their websites for articles and documentation to support this.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  4. #4
    Location
    Grants Pass
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    40
    Default thank you!
    thank you for your responses. I greatly appreciate it.

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