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Wiki Auditing free text in an electronic medical record

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Nancy00

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When auditing free text in the electronic medical record, do you count the information in that text towards the level of service?

Thanks so much for your speedy response!
:confused:
 
Yes. If the doctor free texts an HPI, ROS, Exam - etc. all of that information can be used and applied to appropriate sections to obtain your level of service. Anything the doctor documents is applicable.
 
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