Author Topic: Documentation  (Read 1175 times)

dermbillerPA

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Documentation
« on: January 13, 2014, 05:16:32 PM »
Does anyone know if its acceptable to replace a written description with a marked diagram in the chart?  For instance:  Skin biopsy done on left forearm and the body diagram is marked as such. Or melanoma excised from trunk and site is marked on body diagram.  Can this documentation replace a written description? And I'm not referring to replacing an op note. I've checked some carrier policies relating to documentation, but found nothing this specific.  If anyone does know can you back it up with supporting documentation?  Thanks so much.

Michele

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Re: Documentation
« Reply #1 on: January 14, 2014, 08:12:33 AM »
I tried to find documentation on this but wasn't able to.  However, my personal belief is that as long as the information is charted it shouldn't matter whether it is written or a diagram.
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PMRNC

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Re: Documentation
« Reply #2 on: January 14, 2014, 11:25:13 AM »
I would say it matters WHO puts it in there..  ;D
Linda Walker
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Michele

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Re: Documentation
« Reply #3 on: January 15, 2014, 09:32:00 AM »
Good Point!   :D
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PMRNC

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Re: Documentation
« Reply #4 on: January 15, 2014, 10:38:22 AM »
As a biller and even coder I stay out of clinical things like this. If it's a part of an appeal I send in the clinical documentation needed and if there is a question I have the provider make decisions where clinical documentation is concerned.
Linda Walker
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asilva03

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Re: Documentation
« Reply #5 on: January 16, 2014, 07:36:25 AM »
Linda,

That is exactly how I do it. I do not get involved unless necessary because of the liability that will be placed on the biller and/or coder. I understand my role as both but also the doctor's and I know that I would feel much more comfortable placing the responsibility of what goes in the chart with the doctor.