Internal Medicine Coding Alert

Question: This past July we billed 99213 for an office visit. Now, the patient's insurance company wants to see the internist's documentation for the visit. Because the physician either lost the notes or did not document the E/M, she says she can document it now. Can she legally do that?

Louisiana Subscriber

Answer: Dictating the medical note and then submitting it as though the internist performed the documentation on the actual date of service would be fraudulent. Your internist should document in the medical chart that she either lost the notes or failed to record the office visit. Then, the physician should redictate the visit, clearly indicating that this is a late entry.