Complete the Record

Question: If a physician checks or writes a diagnosis on a charge ticket but didn't note the diagnosis in the medical record, can the biller code the diagnosis that is on the charge ticket? Is the ticket a sufficient record for billing?

Answer: According to Susan Callaway, CPC, the charge ticket is not sufficient documentation. It is not part of the medical record; the diagnosis must be in the record. The physician can make an addendum if needed.