reewriter
Guest
Hello! I desperately hope someone can help! I code for an orthopaedic surgeons' office and frequently get inpatient consults to charge which I'm familiar with and I receive a copy of the dictation of. However, we have some docs who do their own coding and will submit to me a sheet with the initial inpatient visit and then anywhere from 1 to 3 additional codes for follow-up visits. When I asked for documentation of the follow-ups, the surgeons told me "it's in the patient's hospital chart; just go ahead and bill using the codes I gave you." This makes me very uneasy because I can't see anything in writing to support the code they are giving me (we are not EMR so I can't see anything on the hospital side). I can't find anything official in writing on the documentation requirements for follow-up visit billing on our end of it (the office). Does anyone know anything about this? Can I go ahead and just bill, trusting that whatever the surgeon documented in the patient's inpatient chart will suffice? I really don't know where to go with this and obviously don't want to miss any charges, but at the same time I don't want to bill fraudulently, of course. ANY INFO would be greatly appreciated!!!!