heatherwinters
Expert
If a patient has 278.00, 401.9, 250.00, 272.4 and 268.9 and on the bottom of the note in the labs ordered section, the doctor circled are CMP, CBC, A1C, Lipid Profile, Urine microalb/creatinine.
Would an auditor match each dx to the lab test that was circled at the bottom, or does the doctor have to match them up in his documentation of the visit.
What is considered "easily discernable" in Medical Documentation? Is a list of dx on assessment, then a list of labs on the progress note acceptable or does he have to tie each test he orders to the specific matching dx in the progress note.
Would an auditor match each dx to the lab test that was circled at the bottom, or does the doctor have to match them up in his documentation of the visit.
What is considered "easily discernable" in Medical Documentation? Is a list of dx on assessment, then a list of labs on the progress note acceptable or does he have to tie each test he orders to the specific matching dx in the progress note.