Wiki Question regarding CPT coding for missed documentation

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cwestman

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I'm wondering if anyone can advise me on a coding issue. Patient was seen in Primary Care setting for a follow up visit. At the time of the visit the patient requested joint injections for bilateral knee pain. The Provider coded the visit as 99213 and added the J code for the Kenalog, however he did not add the procedure codes for the injections (20610). These codes were added at the claim level, is it inappropriate to add these codes at that level as they were not documented in the note. I have always been advised, if it's not in the note it didn't happen.
Personally I feel it would have been more appropriate to query the Provider and have an addendum to the note
I guess I just need to know if this is appropriate,or would this be an issue when audited
Appreciate feed back
Thank you
Cheri(CPC-A)
 
Nope. it needs to be documented, If audited the money would be taken back and every other injection could come under scrutiny as well. Whether addendum can be done, it will depend on how long ago it was. All amendments to medical records must be made in a reasonable time frame. Reasonable is normally understood to be 24-48 hours after date of service.
 
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Question regarding CPT coding for missed documentation

CodingKing
Nope. it needs to be documented, If audited the money would be taken back and every other injection could come under scrutiny as well. Whether addendum can be done, it will depend on how long ago it was. All amendments to medical records must be made in a reasonable time frame. Reasonable is normally understood to be 24-48 hours after date of service.

CodingKing -

Is there anything that supports the 24-48 hour guideline you've indicated? It has been my understanding that a medical report/documentation can be modified if the provider does it within thirty (30) of the date of service. After thrity (30) days it can no longer be modified.
 
Missed code or missed documentation?

cwestman said:
I'm wondering if anyone can advise me on a coding issue. Patient was seen in Primary Care setting for a follow up visit. At the time of the visit the patient requested joint injections for bilateral knee pain. The Provider coded the visit as 99213 and added the J code for the Kenalog, however he did not add the procedure codes for the injections (20610). These codes were added at the claim level, is it inappropriate to add these codes at that level as they were not documented in the note. I have always been advised, if it's not in the note it didn't happen.
Personally I feel it would have been more appropriate to query the Provider and have an addendum to the note
I guess I just need to know if this is appropriate,or would this be an issue when audited
Appreciate feed back
Thank you
Cheri(CPC-A)
Click to expand...

Hi. I found your question a bit unclear. Did the provider fail to document the injection service (e.g., patient consent, site of injection, drug name, lot number and expiration date, etc.) or just fail to include codes for the injections in the note? Codes are not required in documentation but are incorporated in most EHR systems. If the procedures were documented, it is appropriate to bill unless the provider indicates there is some reason not to bill (eg, patient requested to pay and not bill insurance).

Cindy
 
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