Inconsistent Diagnoses Documentation Throughout the Medical Record
We often see diagnoses documented in the Progress Notes that are treated but are not brought forward in the Discharge Summary and vice versa...diagnoses in the Discharge Summary that are not consistently documented in the progress notes. This is identified by the coding auditors who perform pre-bill audits.
Has CMS published any guidelines for their MACS which state if the documentation is not consistently documented throughout the chart and in the Discharge Summary, the MAC may remove a diagnosis that has been billed due to inconsistent documentation throughout the chart?
Has CMS published any guidelines for their MACS which state if the documentation is not consistently documented throughout the chart and in the Discharge Summary, the MAC may remove a diagnosis that has been billed due to inconsistent documentation throughout the chart?