HIPAA > HIPAA
Proof for HIPAA
Michele:
Do you work for the Dr (in his office)? Or are you a billing service? Just curious. Anyway, the injection should be documented in the patient's chart and I'm surprised (disappointed) that the provider thinks it's ok not to chart it.
I'm curious to see Linda's answer on this.
I think you are in a very unfortunate situation if this is your job. But I also think this cannot be the only area the dr is not following the rules. Since you are very aware that it's not documented, you cannot bill it. A superbill is not a patient's chart. It doesn't contain enough info to be considered documentation.
Michele
Annacate:
Thanks Michelle. I have really been struggling with this knowing that I will have to make a decision about my employment. I appreciate your imput on this and WILL NOT send claims if there is no documentation. So far it has been just the medical assisant not charting injections but the doctor is charting adequantly as far as I can see. However, the doctor will not stand behind me in this. I am currently trying to get my coding certification by March and maybe I can then find a coding position. It is very unfortunate that the doctor I work for does not realize I am just trying to help her when I tell her about these issues, instead she thinks I am telling her what to do and told me I was trying to make extra jobs for the MA. Again, thanks for your imput.
Steve Verno CMBS, CEMCS:
A superbill is NOT a medical record.
I went to a doctor, he presented a superbill with a level 1 visit circled. His biller changed it to a level 2 visit. Ive submitted 2 certified requests for a copy of the medical record and have been ignored. My next letters wll go to the Office of Civil Rights, OIG, and Department of Health.
Another doctor insists on billing me for cre he didnt provide. My request for a copy of the medical record resulted in getting a superbill. In his phone call, he also insisted that the superbill was sufficient. He's now under investigation for fraud and he may lose his license. He was warned 3 times he never provided what he circled on the superbill. He just sent the account to his collection agency which could result in a lawsuit and federal investigations.
Anything billed must be supported by the documentation in the medical record. Your State medical record law may specify further requirements. Medical Record Rule: If it isnt documented in the chart, it doesnt exist AND you document the chart as if it were evidence in court.
blhoffman:
I know this is a little late to the party but I would like to post this in response to the original question.
In the large health insurance agencies I've worked for we had to take somthing similiar to this every six months. Same concept but different company. So I would like to continue it for compliance reasons. I plan to use this company.
http://www.hipaaexams.com/index.html
annaevans:
I know this question was started in April however, I did find some interesting resource that might help the original person about demonstrating HIPAA compliance for her home based business. Now I have not looked at the actual manual but American Medical Billing Association (AMBA)has a manual for members not sure about non members for $69.00 with sample. Try this URL for a direct link to it www.ambanet.net/compl_manual.htm Not sure if this is what your looking for but maybe it could be of some use in your journey. Thanks, Anna Evans
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