Results 1 to 8 of 8

Is this legal?!?

  1. #1
    Location
    St. Louis Professional Coders
    Posts
    5
    Default Is this legal?!?
    Medical Coding Books
    I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

    He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

    He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

    I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

    If an audit took place, it would be ME in a sling. not him.

    Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?

  2. #2
    Default
    Quote Originally Posted by kobrien View Post
    I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

    He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

    He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

    I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

    If an audit took place, it would be ME in a sling. not him.

    Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?
    You said "I feel this is wrong because neither an OP note nor a sticker is a legal document" and then "Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR?".
    So, do you want to code from OP report or not? If you think OP report is not a legal document the what is the legal document that you want to code from?

    Op report should have Pre and Post Op Dx as well as Planned and Performed procedures. I would not get Dx from other notes.

  3. Default
    An OP note is not legal UNTIL it is signed.
    A patient sticker is NEVER a legal and binding document.
    As far as compliance goes, I am sure there is a compliance policy that addresses these concerns. Do not know exactly where to find them.
    Anybody have any ideas?

  4. #4
    Location
    St. Louis Professional Coders
    Posts
    5
    Default
    Caromissunc1, I am glad you are following up on this.

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by kobrien View Post
    I am having a compliance issue with one of my docs. He wants me to code joint injections surgeries from a patient sticker with the location.

    He would also expect me to code some surgeries not only off the OP note, but to get other diagnosis codes from inside the EMR as needed to support the surgery, since he is too busy to dictate them all. So as to expedite his reimbursement.

    He would also like me to code certain surgeries from an OP note that he has not signed yet. Again, to expedite his reimbursement.

    I feel this is wrong because neither an OP note nor a sticker is a legal document. When I mention this to him, he blusters about being one of the heads of the company, and I should do as I'm instructed.

    If an audit took place, it would be ME in a sling. not him.

    Is there a blanket compliance rule somewhere in writing that states that claims are only coded by the OP note and NOT the EMR? They must be signed? And the penalities that would occur if these compliance violations were discovered?
    Not sure if you'll find what you need here, but maybe it will provide some information you'll find useful.

    Pg 7 of 9-25-2000 link speaks about documentation. I would review any link that is applicable to your type of setting.

    http://www.oig.hhs.gov/compliance/co...ance/index.asp

  6. Default OP Notes are legal docs.
    I know that OP notes are legal documents. Stickers and unsigned OP notes are not.
    I know that OP notes are coded by themselves as they are a "stand alone" document. If for some reason they are denied, or the insurance company wants documentation, we send only the OP note, not the entire EMR.
    What I really need is the documentation that states the above issues regarding OP notes and the validity of signatures.
    I have looked on the CMS and Federal Register websites, and cannot find what I need. How do I explain to the doctor that this is a compliance issue if I cannot find any compliance documentation to back me up.
    Help!!!

  7. #7
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by caromissunc1 View Post
    I know that OP notes are legal documents. Stickers and unsigned OP notes are not.
    I know that OP notes are coded by themselves as they are a "stand alone" document. If for some reason they are denied, or the insurance company wants documentation, we send only the OP note, not the entire EMR.
    What I really need is the documentation that states the above issues regarding OP notes and the validity of signatures.
    I have looked on the CMS and Federal Register websites, and cannot find what I need. How do I explain to the doctor that this is a compliance issue if I cannot find any compliance documentation to back me up.
    Help!!!
    Begin reading page 33 and see if this is what you're looking for. It provides signature guidelines and a grid that indicates what is and isn't allowed.

    http://www.cms.gov/manuals/downloads/pim83c03.pdf

  8. #8
    Location
    Fort Worth Chapter
    Posts
    36
    Default "you should do as your instructed"
    I hope you find what you need!
    Even if you do, I imagine that it won't change his mind.
    If all else fails, inform your doc that you dont look good in "county orange".

Similar Threads

  1. Is this legal?
    By dballard2004 in forum Billing/Reimbursement
    Replies: 3
    Last Post: 07-26-2011, 09:46 AM
  2. is this legal?
    By ness01 in forum Medical Coding General Discussion
    Replies: 5
    Last Post: 02-23-2009, 09:51 AM
  3. Legal Question
    By medcode12 in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 10-09-2008, 09:33 AM
  4. Is this legal?!!!
    By dede470 in forum Medical Coding General Discussion
    Replies: 9
    Last Post: 01-05-2008, 09:03 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.