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Auditing free text in an electronic medical record

N

Nancy00

Contributor
Messages
21
Location
Austin, TX
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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