Wiki altering Drs progress notes

[Karen A.]

I am new to E&M billing, my experience is in billing surgeries from Op reports. I work for a group OB/GYN practice that uses EMR. The EMR system allows the Drs to "click" items in the MDM section-indicating they reviewed or ordered labs, imaging, rx, ect to help the EMR select the level of E&M service for them. Several of our billers, with the OK of the Drs, are opening up the Drs signed progress notes and "fixing" what the Dr neglected to click. They are then billing out the level of E&M the EMR selects. The Drs resign their note at a later date. This seems wrong to me, but I am unable to find anything to back this up. At least, it seems the billing should not take place until the Drs review and resign their progress notes.
Can anyone offer me any guidance with this?

 

[mitchellde]

They are called physician notes for a reason! A biller is never ever to add or subtract information from a physician note regardless of whether he signs it later. The biller has no way to 100% know what items to check. This is not a good practice at all. The provider is the one that makes amendments to his/her own note. If a gap is detected by the coder/biller then the documentation should go back to the provider for amendment.

 

[LindaEV]

They are called physician notes for a reason! A biller is never ever to add or subtract information from a physician note regardless of whether he signs it later. The biller has no way to 100% know what items to check. This is not a good practice at all. The provider is the one that makes amendments to his/her own note. If a gap is detected by the coder/biller then the documentation should go back to the provider for amendment.

Agree 100%!! Any good EMR system will show who made the changes...if not outwardly visable, then maybe behind the scenes...and this could come back to bite you...also if the physician is sharing their password, this is not ok.

The OIG has a focus this year on the EMR...check out their websites for articles and documentation to support this.

 

[Karen A.]

thank you!

thank you for your responses. I greatly appreciate it.