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Question about auditing an E&M

  1. #1
    Cactus Coders
    Default Question about auditing an E&M
    Medical Coding Books
    I do mostly post payment auditing and I ran into one last night that I had never seen before and am hoping to get your opinions on it.

    The physician sent in his records, which was really just a flow sheet with multiple dates of service on it. Each dos had a few scratches and markings, which I'm sure made sense to him but did nothing for me. Included with his flow sheet, he addressed a letter to my company stating that he'd like to explain what the visit was about and what was done. He preceeded to do a full level 3 dictation in this letter.

    The letter to my company was written two years after the encounter. One of the ladies I work with said to go ahead and audit off the letter as though it was an admendment to the dictation, but I'm not so sure that correct. This letter has not been apart of the patient record, and had this been an on-site audit he certainly wouldnt have been allowed to write letters for each of the charts dictated.

    What do you think? Thanks in advance.

  2. #2
    Columbia, MO
    even if he wanted to add the letter as an amendement to the encounter he could not since the claim had already been processed. No you cannot use the information in the letter to audit his coding of the claim. It was not there when the claim was submitted so it does not exist.
    Last edited by mitchellde; 06-25-2011 at 04:25 PM.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Cactus Coders
    Thank you for responding Debra. That was my feeling as well!
    Tracy L. Duran, CPC, CEMC, CGIC, CGSC, CIMC
    Lead Coder

  4. #4
    Default auditing
    I audit from a payer standpoint - the official medical record must have contemporaneous documentation.


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