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Lorijo

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I work for a medical management company. We review documentation against claims that are submitted. When determining the MDM, can the diagnosis codes listed on the HCFA be used? I don't agree that they can be used as the HCFA is not part of the medical record.

thank you!
 
I agree. MDM is determined by what is documented. IDC-9s on the HCFAs are just a numerical translation of what was documented. Hopefully, the correct ICD-9 was chosen and/or matches what was documented! :)
 
I agree! There is a problem in my mind if you are wanting to use the dx listed on the HCFA instead of the chart note for the MDM since the chart note and HCFA must match. Perhaps you meant, the dx codes listed on the superbill, in which case no the only dx that matters is what is in the exam portion of the chart note and that is what is listed on the claim ( HCFA)
 
Then it goes back to the provider, if there is nothing there it cannot be coded,
is it possible to post the note? Could it be that it just needs a V code as in a follow up?
How is there ia HCFA(claim) with dx codes then??
 
Wait you said you are reviewing after the claim has gone out? and there is nothing in the documentation to support what is on the claim? then the chart note cannot go back for revision. My advice would be to refund the monies paid, and /or submit a corrected claim. then perform a 100% audit and review for this provider. who does the coding on the front end? I have many questions, but you cannot use the claim to support the documentation, you use the documentation to support the claim.
 
The key here, is that you are reviewing the documentation to verify that it supports the codes that were billed on the HCFA - therefore, the diagnosis (es) must be covered in the documentation.
 
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