llhogeland
Contributor
Does anyone know the guidelines as they relate to coding and billing surgeries off of an incomplete or unsigned op note. If 99% of the op note is complete and there is ample information to code and bill based off of the op note as it is, is it out of compliance to go ahead and bill out the surgery if the note at that time is not 100% complete and signed by the surgeon. The hospital appears to go ahead and bill and sends us the incomplete op note, but they do not send us the completed one, we have to go out and pull it from the hospital site. The doctors are often a bit slow at going back and filling in their blanks and signing off after the dictation is done therefore it is hard to gauge a time frame to go pull the completed notes. Does anyone have any answers and/or suggestions in this situation? 