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ksue

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As a fairly new coder I just started working at a billing company. The documentation of the providers clinical notes have not been optimal no dm connections, wound vs ulcer etc.
The biller would like me to pick up DX or underlying conditions DM w/Other spec. manif. from part of the wound care assessment which is completed by the nurse, previous progress note or H&P.
To me as a coder this is a big no no! The note has to stand alone..am I correct here? Or for audit purposes do you only need 1 good note which includes the wound care assessment initial H&P etc? The biller says during an audit she submits everything so I should not worry as they will find the H&P or other documentation etc. Im concerned as we have lots of debridements etc and we have to abide by the LCD's for medical necessity. Does anyone know if you only need 1 good note for audit purposes or is it note by note basis. Appreciate any feedback!
 
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The documentation for the date of service billed has to support the code billed. You cannot use previous documentation to justify billing a code on a different date of service. You are correct in the documentation should stand alone.
 
I have worked as an auditor for Medicaid and many times a lot of extra documentation was submitted for review, I never looked at any of it. Neither did the supervisor or the attorney when unfavorable decisions were made.
 
compliance

Thank you so much!! this is exactly what I needed to confirm. I absolutely want to be compliant and appreciate your feedback and knowledge.
 
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