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Wiki dictated report

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J

Jlokloski

Networker
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Clio, MI
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When coding an office consult how much of the information needs to be dictated into a letter versus what can be pulled out of the chart from the intake form that the MA fills out? And if the doctor initials the form but does not refer to it in the letter, can it be counted towards the review of systems and physical i.e., the blood pressure, weight, etc.? Also, can we use the information on the router when coding, i.e. the labs ordered if he doesn't actually dictate this into his letter.

Thank you for your help.
 
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