BeckyL1958
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I am one of two coders currently working for a group of urologists, I've only been here a month. We are expected to code without progress notes or a chart. The physicians and the NP and PA do their own E&M coding which is consistenly wrong. I was hired to audit their charts but sometimes am expected to "code" from the fee tickets. I am NOT comfortable doing this and usually end up pulling the chart to read the documentation, it rarely supports the level being billed. I have twice brought up the fact that we are coding blind but they will not change anything at this point. My question; is this acceptable? We as the CPC's are required to initial whatever we code. I've always had at least a copy of the progress note attached. If Medicare came in and did an audit, who will ultimately be responsible for the coding?