Wiki Advice Needed!

[joanne71178]

Is it not unethical and/or against rules and regulations to code a diagnosis if it is missing from the OP note? I have an office I am coding surgeries for who have left a diagnosis off an OP note and refuse to give anaddemdum. They want to verbally give me the diagnosis.

Please help.

 

[em2177]

If it is not documented it doesnt exist.....

 

[drjohnson]

Lack of Dx

Federal Register/ Vol. 63, No. 243/Friday, December 18, 1998/ Notices

Among the risk areas the OIG has identified as particularly problematic are;
1. Billing for items or services not actually documented
2. Upbundling
3. Upcoding
4. Inappropriate balance billing
5. Inadequate resolution of overpayments

 

[joanne71178]

What if they want to send the diagnosis through email to attach to the OP note? Would that be acceptable?

Thank you!

 

[mitchellde]

no I think not, he must append the medical record himself. Why is the provider not wanting to append an addendum?

 

[joanne71178]

You support my thoughts on this. My guess why they don't want to ask the Dr. to dictate an addendum is because the surgery date is 11/27/12. I emailed the Manager on 11/29/12 asking for an addendum w/no response until recently. This is when they emailed the diagnosis code and I told them that was not sufficient.
Thank you for your response.

 

[mitchellde]

Good for you! are you an off site billing service? I am just curious no other reason.

 

[joanne71178]

Yes, I am off site.