Wiki Can we code from Visit summary after completion of Signature ?

[surajdk]

Can we code, clinical summary, visit summary code after signature complete in Hcc coding.

 

[athomas4]

I was told No unless you can verify the visit summary is for only that visit and it if contains PSH, Family history. But then again this is for the company I work for that allows only that Info to go by.

 

[surajdk]

I was told No unless you can verify the visit summary is for only that visit and it if contains PSH, Family history. But then again this is for the company I work for that allows only that Info to go by.

Thank u

 

[Pathos]

I agree with athomas4. When you use documentation to support HCC coding and a condition, there should be no doubt that the condition is active under the MEAT/TAMPER guidelines. I would be very hesitant to use the Clinical Summary/Visit Summary for HCC coding. I would rather focus on the rest of the chart (History, Exam and MDM) for your main source of documentation. And again as athomas4 eluded to above, the company you work for also has to make a determination on the amount of risk they are willing to take. This should be done through internal policies and processes.

Hope this helps!