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Chart Audit Question

tnapora

Contributor
Messages
12
Location
Torrance, CA
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0
Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
Thank you!
 

colleenwade

Guest
Messages
23
Location
Garden State Chapter, Cherry Hill, NJ
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In the 1997 guidelines, under Amount or Complexity of Data, one of the documentation guidelines states:
"DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as 'WBC elevated' or 'chest x-ray unremarkable' is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results."
 

rthames052006

True Blue
Local Chapter Officer
Messages
1,905
Location
York, Pa
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Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
Thank you!
Not documented, not done....
 

member7

Guest
Messages
79
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0
When a third party auditor reviews the chart what is normally looked for is reason for the procedure, a physician's order, a supporting diagnosis, the procedure report, and acknowledgement of that report either in the progress notes or on the report itself.
 

eRicK@

New
Messages
6
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0
I would only code if it is documented and diagnose by the physician in the progress notes.
 
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