Wiki physicians documentation

[tmcquegge]

I have posted before that our physicians think that they only have to choose a code and that is what they need for specificity even though we have told them over and over again that they have to say in there own words example the patient lipids are stable they need to say the patients mixed hyperlipidemia is stable... I'm looking into having someone come in and talk to them probably another physician because a physician has even said I wish we could get this verified by someone outside of our company... GRRRR so my question is anyone know of a place/company to look into. We don't really want "training" just someone that will speak to the docs and once and for all explain to them what they need to do..... Thanks for any help.

Tara M.

 

[Cheezum51]

Easy. They either start documenting their interpretation of testing or they may be audited and fined for not doing that. The fines can add up to hundreds of thousands of dollars!

The stand by saying is: "If you didn't write it down, you didn't do it." Which also means you can't bill for it.

 

[senthillp]

Kyphoplasty clarification

Hi,
need clarification about medicare denial. Procedure done for Kyphoplasty/VERTEBROPLASTY, indication is history of subacute vertebral compression fracture of T5 vertebral body, associated with severe pain. here i coded 22513 with 733.13, but medicare denies with needed for 2ndary dx code, please advise patient is 73 yrs and had injury to spine and spinal cord due to birth trauma, can i give bone disorder for 2ndary dx..please advise