I have some concerns regarding coding documentation. I have expressed my concerns with my Office Manager and he seems to think that I am over thinking it. My concern is this: patient is seen in office for a 3 week follow up for HTN, hyperlipidemia, CKD, aortic stenosis and bilateral knee pain. The provider documented in his note that the patient opted for Cortisone injections for the knee pain. Provider documented the E&M, and the J3301 for the Cortisone, however he did not document in his note the CPT 20610 codes indicating the joint injections were done. If the 20610 codes are being added at the claim level, shouldn't they be documented in the note? I have been told that this isn't something that is looked at in an audit. Am I correct to be concerned?
There are many reasons when not reporting a procedure is considered improper coding. If this encounter was properly coded, the E/M would be reported with a modifier and then report the procedure in addition to the J-code. The claim may get paid this way, however; that does not mean this is correct. Not to mention it this claim was audited, lack of documentation for the injection, may result in a request for refund. The E/M visit reported would not support the use of the drug. Don’t get me started on a coding mistake that leads to lost revenue Coding mistakes like this can add up quick, this one procedure could have increased the revenue for just this visit around $200. If the office does 4-5 each week there is a loss of at least $4000/mo. Should I go on?