Wiki Coding from questionable/unofficial "medical record"

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codeseeker

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I posed this question last year, but I am resubmitting it (somewhat modified) since the issue has resurfaced:
I am questioning the legality and ethical propriety of coding and billing medical procedures from the physician's handwritten notes on the patient's hospital face sheet or registration form. There are only a couple of handwritten words such as "cystourethroscopy-Bx" or "cystourethroscopy with calculus removal" and a Dx code or Dx description (physician does not record "xyz urethroscope device inserted to xyz site …. , observed xyz"). For the E/M portion, the doctor is just writing (for example) "99215", but no notes support the E/M level selection or what was done during the E/M encounter. I do not know if that these handwritten notations ever make it into the patient's MR; there is no signature on it. I believe it is unethical to code and bill from records that are not part of the legal patient MR. What minimum level of official records are required for me to code and bill from? Although the physician has primary responsibility for maintaining his MR system, I assume as a coder/biller, I share legal and ethical responsibility to bill from a legal MR (is this true?). Unfortunately, there does not seem to be clear cut written guidance on this so I am asking the community for their educated opinion. Thanks a million!
 
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All charges and codes that are submitted on claims must be supported by the patient's medical record and must be signed/authenticated by the provider who performed the services. Notes may be handwritten, but still need to be signed and contain enough information to show that the code is fully supported. I've included the link below to the CMS signature requirements which you might find helpful.

That said, I do know that many physicians communicate with their billing and coding staff by bringing a face sheet back to the office and writing on it, or on an attached charge ticket, the codes or brief descriptions of the services they have performed. Notes such as these are not part of the legal medical record, but in such instances, the documentation to support these services is presumably in the patient's chart at the hospital, and the physician has essentially coded the services themselves. In the event that the payer audited the claim or requested supporting information, those hospital records would need to be obtained because a hand-written code or name of a procedure without the operative note would not be sufficient by itself.

In the event that there was insufficient supporting documentation, I don't think a coder would be held legally responsible for taking the code off of the sheet and putting it on the bill if that is the office's practice, since they are not actually coding the encounter in those cases. But most practices that allow physicians to code would at the very least, as part of their compliance program, have some way to monitor physician's coding accuracy and would periodically sample the actual documentation and have a coder validate it to ensure that the claims that are being submitted are correct. Hope this helps some.

 
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