Hope someone can shed light for me
I was trained to code from "notes" tab in chart review. In the note the Dr is stating "no past surgical hx on file" (they still dictate)
but , If I look in the "encounters" tab I can see the link to history, and I can see a history entered WITH a surgical hx.
Can I count this for E/M? even though doc is stating no hx on file in his note?
would an auditor even look for the link if doc is stating no hx?
any thoughts would be helpful
thx
I was trained to code from "notes" tab in chart review. In the note the Dr is stating "no past surgical hx on file" (they still dictate)
but , If I look in the "encounters" tab I can see the link to history, and I can see a history entered WITH a surgical hx.
Can I count this for E/M? even though doc is stating no hx on file in his note?
would an auditor even look for the link if doc is stating no hx?
any thoughts would be helpful
thx