Wiki debate on what is correct---any advice would be helpful

[micki127]

Hello,

There is a debate going on about what is proper coding.... Is it proper coding to get all the info from the office Visit Note or can you supplement the Office Visit note with the encounter form, physical history form and a form that has all procedures typed on it and the provider is checking off the boxes of what the patient had done ie, x-rays, injections and the like.

So in a nut shell is it adequate documentation that if a provider does not dictate in an Office Visit note what the diagnosis is but he writes it on the encounter form then that is accurate enough to code off the encounter form what the dx is?

Any advice will be much appreciated

 

[monopoly222]

What is your office policy?

What is your office policy? Who is actually responsible for the coding? Do you keep ALL paperwork including the encounter form, physical history form and provider check off sheet?

The doctor should dictate it. IF he refuses, make sure you keep EVERYTHING.....just in case you get audited.

You need to come up with an office policy who is responsible for the coding? Doctor and Coder? I was forced to make my doctor responsible in our office policy because sometimes....he doesn't like to listen to my coding advise.

AND.....right before I was hired......he got into trouble with his coding....not following coding guidelines....he came back and bit him hard to the tune of $25,000 plus lost his contract with that HUGE insurance company....

Of course, he didn't tell me until after I was hired so I was blindsided when I started.....that is why I had to come up with the current office policy we have. I tell my provider......I will not code illegally........I will not go to jail for anyone. lol.

Not sure if this helps but I hope it does even just a little.

Good Luck.

debate on what is correct---any advice would be helpful
Hello,

There is a debate going on about what is proper coding.... Is it proper coding to get all the info from the office Visit Note or can you supplement the Office Visit note with the encounter form, physical history form and a form that has all procedures typed on it and the provider is checking off the boxes of what the patient had done ie, x-rays, injections and the like.

So in a nut shell is it adequate documentation that if a provider does not dictate in an Office Visit note what the diagnosis is but he writes it on the encounter form then that is accurate enough to code off the encounter form what the dx is?

Any advice will be much appreciated