# Dr documentation



## bkwrmz7 (Apr 26, 2013)

I need help. How do you (politely) tell a Dr or a FNP you need more notes in order to bill the visit? I have a new patient visit that the Dr says "43 yo male presents w/a multitude of issues, rescheduled to discuss referrals" I had a FNP dx hypothyroidism but there was nothing to substantiate the dx within the visit note, when I asked for more notes regarding it, she told me "I've been doing this for more than 20 years I know what I'm doing".


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## Candice_Fenildo (Apr 27, 2013)

Here is an audit tool worksheet that may help you and your physician. Remember it is all abou the approach. You do not want to come off as you are telling the provider that they are documenting wrong, just that the practice in a whole needs to add to the documentation to substantiate billing that particular level of E/M.

http://static.aapc.com/a3c7c3fe-6fa...224e/acf30888-226c-419d-a051-02e5b4cbb010.pdf


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## Grintwig (Apr 30, 2013)

The link does not work for me


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## Candice_Fenildo (Apr 30, 2013)

If you email me, I will send it that way.


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## hstrasko_rn@atlanticlegalnurseconsultants.com (May 24, 2013)

Just food for thought. Most Professionals ears perk up when the bottom line ($$$) may be effected. Meaning...if they do not properly chart....you are going to have a impossible task of getting their charges through for proper payment. Then the trickle down effect kicks in. A lot of this has to do with the way the situation is presented.  I've just returned for our State Bar's Convention, and if some of you have noticed MCR-Medicare payments slowly coming in---there's a major audit going on with Providers. These audits are done by MD's, RN's, CNP's, etc.  The charting MUST be in line with the treatment provided to bill the proper CPT code. It is not worth being sanctioned or their license being suspended because it appeared as if fraudulent billing was taking place. There really is no excuse for a Provider not to be bothered charting properly. The Insurance Carriers won't accept any!  It so happens that I do audits and this can have a profound effect on their practice. i.e.The Dr needs to know that their patients receive notification when their Dr is fined by Medicare for improper coding, billing, etc.  Perhaps gently putting this into someone's ear that you are there to protect their practice and why your concerned may help the documentation situation!
Helen Strasko, RN, CLNC
Atlantic Legal Nurse Consultants


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## bprater (Jun 2, 2013)

*Auditing*

I would like to know if anyone has this situation in their office where the physicians tell the medical assistants to pick their codes for them.  Is there anything anywhere in writing that it should only be done  by a physician or a CPC?  HELP!!!


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## mitchellde (Jun 2, 2013)

As long as the codes are selected based on the coding guidelines and the documentation in the chart, there is no rule regarding who selects the code.  However the responsibility for the code that is placed on the claim lies with the one that creates the claim and the physician.


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## MarcusM (Jun 5, 2013)

*Documentation*

If it is not written down, it never happened.  Documentation by the doctor is essential to getting reimbursed correctly for the time spent and not having to pay back funds at a later date when the RAC guys come knocking on your door.  And since RAC auditors get paid based on what they collect, guess what? They will find issues with the documentation.  As far as others besides the doctor picking the diagnosis codes, I would make sure the doctor approves any unusual codes...reading an "irregular irregular heart beat" in a chart note is not an error, but a viable medical condition of the heart.  But I asked my cardio doctor to confirm this diagnosis.


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