We are a super busy RHC with a hybrid record- keeping system. We have paper charts with fee tickets, and also our EHR.
Only one of our doctors uses the EHR for patient encounters, but nurses, lab tech, and XRay tech all use this to account for procedures.

The doctors use the fee tickets to capture the E/M level, they’ll circle any procedures ordered, and they will specify any procedures carried out themselves.

What we find is that many of the incident-to procedures or services are captured only on this ticket, and not in the EHR. As coders, we send these back to clarify and account for confirmed procedures. Being busy and low-resource, sometimes it can be a week or two between the actual visit and the nurse query.

Being the only way we track these, it seems a lot of these depend on the memory. Some of these are confirmed to have not been carried out, and we void it on the ticket.

We know the staff answer these queries to the best of their knowledge, but also realize that they couldn’t possibly recollect every procedure within a span of weeks.

Does anyone know of a time frame, rule, or acceptable protocol to follow to help us avoid inappropriate charges due to this?