Hi, I am currently a CRC coder and part of my job along with chart reviews is to re-write progress notes and to do addendums for the providers. I am not a clinician but my company requires us to re write plan of cares. We also have to mention stuff that was not mentioned. Example would be continue to monitor salt intake, reduce sedative from whole pill to half of a pill for sedative dependence, even though not mentioned and even though the provider did not specifically state that anywhere on the date of service or any other date of service. We are also told to use plan of care from previous visits to use for another date of service. I really dont feel this is legal as a coder. Again, I am not a clinician and did not have a face to face encounter with the patient. My boss says that its okay to do this as long as the provider signs the notes and adds it to his chart. Is this legally okay? Please help.
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