tci General Surgery Coding Alert - 2003 Issue 10

Using Documentation Templates? Read This First

You have to base your ICD-9 coding on your physician's documentation, but that doesn't mean you have to accept your physician's form of documentation. Documentation templates may seem like a coding dream come true, but if the diagnosis codes you're billing are looking eerily familiar, you may be basing your coding on "cloned documentation" - a coding and compliance nightmare. If your documentation template allows your physician to check one box for "yes" and another for "no," and it's not individualized for each system, you're at risk of coding from cloned documentation, says Melissa DePasquale, CPC...

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