Coding Cues: Document before you submit

February 15, 2008

We perform diagnostic testing in our office. One member of our group looks at the results while the patient's still in the office, uses that information to help determine the plan of care, but doesn't dictate the results until weeks later. We submit the claim for the testing immediately after we see the patient, but should we hold all claims until the findings are documented?

We perform diagnostic testing in our office. One member of our group looks at the results while the patient's still in the office, uses that information to help determine the plan of care, but doesn't dictate the results until weeks later. We submit the claim for the testing immediately after we see the patient, but should we hold all claims until the findings are documented?

Yes. Although your colleague may indicate a preliminary impression in a chart note that documents the plan of care, you're billing for the complete procedure before the professional component has been rendered. Technically, that's a no-no. Encourage your associate to dictate promptly. You might consider penalizing doctors financially for their tardiness, which is what some practices have decided to do to encourage timeliness.