Wiki late entries for E/M documentation

[fdcook1]

I have a dilemma. I am looking at my NPP's charts prior to submitting charges due to lack of documentation. For the past few weeks (it has been a month now) I have asked him to review patient A and patient B's chart regarding the documentation. It took him a month to complete the patient's exam portion of the documentation. I don't feel that the NPP really remembers what he saw the patients for, and the exam is extremely limited. I don't think I should bill for these services.....am I correct in my thinking?

 

[erjones147]

I'm running in to something roughly similar where I work, and this is just my take on it:

A good provider will still have notes, triages, lab results, etc. handy for a patient - even days later. I would not presume AUTOMATICALLY that the FNP could not remember any given exam or procedure for a patient, so I would code/bill it

That being said, I am going to review that provider's notes very harshly to make sure that I am not just getting a blanket complete ROS or exam for a chief complaint of an ingrown toenail (for example), and I would have no problem downcoding on those borderline cases where it might seem 50/50 for a given E/M code

I work in a clinic where the two providers are both salaried employees, so the providers have less incentive to finish their notes. My clinic director is considering "options" to deal with this

 

[fdcook1]

Thanks Erjones147. Appreciate the help!