codeseeker
Guest
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!
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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