# Billing Insurance without medical documentation



## cwilson3333 (Feb 7, 2013)

Question regarding billing for charges if the doctor has  seen the patient, but did not do his medical documentation on the patient and the only information in the chart is what the patient has completed.

As far as the  medical billing ,I was recently told that it is legal to bill the insurance company from the encounter forms only,  for which a doctor has indicated the level of visit, and diagnosis, even if he has not done any documentation.

Guide me in the direction of the right answer?  

Now totally confused,

WC


----------



## mitchellde (Feb 7, 2013)

The claim must be a reflection of the medical record not the encounter form or superbill therefore no documentation = no claim.  My question is why is there no documentatipn


----------



## cwilson3333 (Feb 7, 2013)

*Reply to billing insurance with no documentation*

No documentation because either chart was filed away before dictation done, and/or did not take time to do after appointment.

I agree, no documentation, no claim.

Do you have a link I can go to on this matter?

Tnx for your response.

WC


----------



## skrautkramer (Feb 13, 2013)

You can check with your MAC usually they have something on their site or even if it is not Medicare you can check with the insurance companies policy on this matter.


----------



## mitchellde (Feb 13, 2013)

the coding guidelines which are HIPAA required to be adhered to state:
The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

you cannot submit a claim without benefit of the completed document.


----------



## AmandaM2153 (Feb 25, 2013)

I hope no one minds that I put a question along with this. I have recently been told that the other clinic we are merging with only "spot checks" 10% of their claims and pushes the other 90% out by what it put on the EEF by the provider. Now they are asking me to only check 20% and push the other 80% through. 

This isn't right is it?!


----------



## mitchellde (Feb 25, 2013)

not by my standards, no documentation =no claim if I am the coder.


----------



## AmandaM2153 (Feb 26, 2013)

Well there is supposed to be notes and usually is (some forget every now and then) but they don't want me to go through every note to confirm the codes the provider entered is correct. 

My problem with that is I know one provider over codes herself, and then others miss procedures or pick the wrong procedures. They have never really been trained on that so are not that knowledgable to "NOT" watch over.

But my concern is for what "really" is the policy -- does everyone else go through each and every chart? That's what I feel is the correct thing to do but they are making me think otherwise.....


----------



## mitchellde (Feb 27, 2013)

I teach to a variety of physician offices in all different specialties in all states.. The answer is varied, some look at every note, some never look at notes, some look at some notes.  
However as I said before if you consider that the claim must be a reflection of the note you cannot submit a claim without a review of the note first.  You as the coder and the creator of the claim are equally responsible for the information you submit, therefore if the claim is incorrect you are as responsible for the claim as the physician.  
I go thru every chart, you have the time to do this, do not let others tell you that you do not have the time.  By going thru the note you can verify that the codes are exactly correct and I see a lot fewer back end rejections and denials than my coding companions that do not read the notes.


----------



## AmandaM2153 (Feb 27, 2013)

So could I possibly loose my certification if I do not check?

It's hard to say no because it is my boss saying this...


----------



## kiku3@ptd.net (Feb 28, 2013)

*My Certification*

I go through every single patient's encounter note, it is MY certification on the line if we are audited and found to be non-compliant.  I would stick to your guns and just tell them that. If after a while you see that their documentation has improved and is consistent you can go to spot checking, but until then, no way, I worked too hard to achieve my certifications to let someone else put them injeopardy!!


----------

