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Proper Documentation

  1. Angry Proper Documentation
    Medical Coding Books
    I need opinions on this please; due to cutbacks I am now coding for some docs in our group that I never have before, here is my issue: coding for a surgeon, he submits a office visit bill slip with E/M circled, however on the notes page he indicates "see dictation number..." the dictation is in the hospital system, it is not dated the only date is the date of dication, it is a H&P and is 6 days later than the office visit and is the same day as the I crazy or is this totally inappropriate, I am assuming he has been getting away with this for who knows how long and here I come along and question it...I need to have all my ducks in a row before I go to my supervisor with this...opinions please...

  2. #2
    Columbia, MO
    I am in agreement with you. With no date for confirmation that this is the note for the office visit then you cannot assume this is the correct one, and therefore you have no documentation for the office encounter. I guess a good question is, is this an isolated incident or is it for every surgery? As it could be just a mistake for one single incident.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Oh no I have at least a dozen sitting on my desk with the same issue!!! Thank you for a speedy reply. Any other opinions??

  4. #4
    Milwaukee WI
    Default It took a while ...
    It took a while but we finally got our docs to dictate the DATE OF SERVICE separate from the DATE OF ADMISSION. They are doing this because they don't want to have to dictate twice ... once for the clinic visit and once for the H&P (which is a hospital requirement). So, they dictate in the H&P format, but the date of service is STILL the date of the clinic visit when they made the decision for surgery. (I'm assuming this is the case for you, as I know it is for our surgeons.)

    E.g. Child presents in clinic on Wed 1-18-12 for evaluation of a "lump in groin". Doctor diagnosis an inguinal hernia that will require surgical repair. Doctor has an opening in his surgery schedule for next Monday and parent is pleased to get this taken care of sooner rather than later. Doctor dictates an H&P format with date of service 1-18-12, and date of admission 1-23-12 (date of surgery). The hospital is happy. The documentation shows the accurate date of service. (The HPI will state that the patient presents to clinic with ....)

    Please NOTE ... it is very clear in this kind of documentation that the service being documented was the clinic visit (even though it satisfies the hospital's requirement for an H&P). And we ONLY bill the clnic visit; we do not bill any E/M for the admission.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. Smile
    Thank you so very much, it certainly does help and gives me the proper way of presenting this to our surgeons in order to document this properly!


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