Dani_k_83
Contributor
We have a provider who is using a hospital template and there will often be blanks within the body of the note. For instance, the header says procedure was performed on Right Elbow. But in the body of the note it will say _x_ elbow was prepped, incision into _x_ elbow.
We are asking that the template be corrected and we are getting push back that it has been this way for years and unless we are having claims denied it is not a problem. Our coding team feel that if the laterality mention in the body of the op note was removed, as long as laterality is listed in the header, we would be okay.
Can anyone provide publication that says that having blanks is not acceptable. I've looked but am not finding much and am starting to doubt myself. My compliance team has not been helpful.
Thank you!
We are asking that the template be corrected and we are getting push back that it has been this way for years and unless we are having claims denied it is not a problem. Our coding team feel that if the laterality mention in the body of the op note was removed, as long as laterality is listed in the header, we would be okay.
Can anyone provide publication that says that having blanks is not acceptable. I've looked but am not finding much and am starting to doubt myself. My compliance team has not been helpful.
Thank you!