Here's a suggestion: have the physicians (if they want coders to use the Tech Report/Nurse Report, etc) to sign that report and it can be used for coding purposes--by my understanding. You might also have them refer to that report in their dictations. I believe either would serve the purposes of solving the "disagreement" you speak of.
As for where there's a guideline, I'm not sure you really need one. From a compliance perspective I can understand the concerns, but if you're coding for the professional component, it is concluded that you would only be utilized records that relate to the professional record (that created by and maintained by the physician).
However, you may wish to visit the ACR website at www.acr.com or the Society for Interventional Radiologists because they may have something stated in terms of clinical and medical practice guidelines--although I doubt that's what you're asking for in this situation. If the physician signs a record--even when someone else may be acting as his/her scribe--that record is considered his/her formal record (or at least part and parcel to the record).
Just my suggestions. I believe your auditor is being prudent, but not very visionary.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join