Wiki Reporting of CPT codes on EMR notes

[jaud63]

I have medical providers in a practice who routinely report CPT codes on their medical documentation per hospital rounds. I have been told previously that this could become a compliance concern, however, because I have not seen it in several years I am unable to locate the reason for this.
Does anyone have any information regarding this type of a situation?

Thank you

 

[MarcusM]

Actual coding of a CPT procedure should always be supported by the documentation. Their use of a CPT code in this case could be considered as reminder of or an estimate of their services, similar to a doctor marking the superbill in an office visit. If you find the level is always higher or lower than what the documentation supports, time for provider education.