Banner
  • Utilizing Medical Malpractice Data to Mitigate Risks and Reduce Claims
  • Industry News
  • Access and Reimbursement
  • Law & Malpractice
  • Coding & Documentation
  • Practice Management
  • Finance
  • Technology
  • Patient Engagement & Communications
  • Billing & Collections
  • Staffing & Salary

Complete the Record

Article

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?

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.

Recent Videos
Stephen A. Dickens
Ashkan Nikou
Jennifer Wiggins
Stephen A. Dickens
Ashkan Nikou
Jennifer Wiggins
What are you looking forward to at the 2024 Tri-State Healthcare Leaders Conference?
Stephen A. Dickens
Ashkan Nikou
© 2024 MJH Life Sciences

All rights reserved.