Wiki Facility vs Professional documentation question

Create Wiki Sort by date
B

Birdie625

Networker
Messages
67
Location
Millers Falls, MA
Best answers
2
Hi, I hope to explain this to understanding. I code for the Pro-fee ortho encounters done in the Facility (IP/OBS/DaySurg). I code from the note I see of Dr. I see the Facility coder may put in a query to provider, it gets answered w/in that queried area and yet I still have my same, un-amended note. My understanding is that the Facility coders can / do use answers in that query to obtain their codes ?? But I dont know if I can (for pro-fee aspect)?? My thinking is that I have to use what I have in front of me and that if any changes, an amended note should be done, "then" I can go from that. ??

Just a rough made up example --- pt has a LT distal rad fx; I see a query (from Facility coder)** is rad fx open/closed? -- answer=open / facility coder codes open.... BUT for what I do (looking at the OP report only and nowhere else) note doesn't mention open/closed, so I would use default-closed. Can I use answers from the Facility query to justify coding open??

Thank you all much! Birdie
 
1
All physician documentation for a patient's care during a facility encounter should be included in a single record. You should not have a situation where there is separate set of documentation for professional services vs. facility services.

Most facility policies would include the documentation of any physician queries as a part of the official patient record, in which case an amendment to the note itself is not necessarily required since that would be a duplication of work for the physician, and you may code the physician's services from that query. But my recommendation would be that if you have doubts as to whether or not the facility's queries are a legal part of the record, that you speak with the manager of the facility's coding department to confirm this.
 
0
Thank you for explaining...You answered my question, even tho I didn't explain very well. All the documents are in the same record....and I totally understand your explanation and I thank you very much :)
 
You must log in or register to reply here.
Top