Auditing Documentation


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I have a question about auditing a physicians documentation. Some physicians document using a template and others only dictate a letter to the referring physician for any type of office visit. I am not sure if this type of documentation is correct and will cover all the key points needed to code an E/M code. The letter does not have a Chief Complaint, however it is documented in writting on a separate form. The letter does not refer to any ROS. The HPI, PSFH, and exam is documented. Please let me know any thoughts on using referral letters as office documentation.
Milwaukee WI
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It's the content not the format that matters

It is the content of the documentation, not the format of it that matters. Whether it is written in the form of a letter to the patient's PMC, documented on a comprehensive EHR format, or scribbled on the back of a napkin (God forbid, but bear with me for illustration purposes) ... as long as the patient is clearly identified, along with the date and place of service, and the provider signs it, it is documentation of the service.

Now, using a template makes it easier on the coder, and also helps to nudge the provider into providing more comprehensive documentation, but I've had providers give a fully documented level 5 new patient visit as a letter to the patient's primary physician. It just takes more work on my part to find the key elements.

The ROS and PFSH can be on a totally separate document, and that information completed by the patient or anyone else. However, to count as documentation for THIS service on THIS date, the physician must indicate that s/he has reviewed the ROS & PFSH and identify where that information can be found. For example: ROS and PFSH on patient questionaire completed mm/dd/yy reviewed today; no pertinent positives; patient denies any xxxx or yyyy.

Hope that helps.

F Tessa Bartels, CPC, CEMC