Wiki Documentation of procedure in the orders area of EMR

[KATHY WILHELMSEN]

When reviewing an office visit in the EMR in search of notes to support documentaiton of a procedure done by staff or providers (venipuncture, joint injections, OMT, etc) and the only place the procedure/technique is documented is in the "orders" area of the EMR, is this acceptable to support billing for the procedure? The debate is that as long as it is documented in the EMR on the date it occured we should be able to bill for the service.
Any guidance and supporting evidence would be greatly appreciated.

 

[AprilSueMadison]

I have no evidence to support what I'm saying and I don't know what your notes look like....

Based on what our EHR produces I would not let my providers do that. Our "Orders" section is simply a line that would say "Excision" or "Biopsy" with no further details. I would send that back to them and ask them to resubmit it. If they want to bill for a biopsy, I want to know how it was done, where it was done, if a blade was used, the size and so on. I'd also like to see the clinical comments such as RO SCC or something.

When they don't submit it to me like that, I know it's simply a mistake and they never mind fixing it.

I also use the rule with my providers that it MUST be in the final document. I used to hear from them that "Well, it's noted in the template" but the template isn't finalized. The doctor doesn't sign off on it and I can't send it to Medicare as a final note. I do NOT consider that a part of the final medical record...everything they do must appear on the final document they generate.

I don't know if this helps you at all, I hope it does though!

 

[Daniel Rowden]

I would be very hesitant to use anything that wasn't in the body of an office note or a procedure note.

For me to code anything there needs to be proof in a note (office or procedure note) that substantiates that the procedure was in fact done and that it supports it adequately with details. I've always followed the rule "if it isn't documented, it didn't happen" and I do not code it.