Orthopedic Coding Alert

Question: Last August, we billed 99213 for an office visit. Now, the patient's insurance company wants to see our physician's documentation for the visit. Because the orthopedist 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: Your physician should document in the medical chart that she either lost the notes or failed to record the office visit. Then, she should redictate the visit, clearly indicating that it is a late entry.

According to the AMA's July 12, 2004, American Medical News Q&A, "The medical record must be accurate and complete before a claim is submitted to any payer, including Medicare and Medicaid ... After-the-fact documentation must be clearly identified as an addendum to the medical record of later date."

But be sure your surgeon's late documentation is based on her notes or dictation, and not based on fear of lost documentation. The AMA article states, "Late entries are always a problem; particularly when that entry appears in the chart after a claim has been made that the physician has failed to do something he should have done or done something he shouldn't have done ... It is important to explain why the late entry is being made so the physician can justify his actions in the courtroom, sometimes several years after the entry was made."

You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.