Wiki consult coding

[vcorso]

Can a coder use the letter dictated back to the requesting dr as the documentation for the visit, i don't think so please help??
If not where can i find documentation to the fact.

 

[LLovett]

Yes you can.

That is actually how many of my specialist document their consults, in a letter format. A copy is sent to the requesting provider and a copy goes in the patients chart.

If they use additional forms (ie ROS, PFSH filled out by the patient) they still need to reference those by name and date in the letter to get credit if the only E/M documenation is the letter.

Laura, CPC, CEMC

 

[vcorso]

thanks for your help.

 

[kte01a]

I completely agree. All documentation for that visit that is signed by the provider can be used as supporting documentation for the billable code.