• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki Documentation of Labs ordered

Create Wiki
K

ktdiamond

New
Messages
1
Location
Hilbert, WI
Best answers
0
If a provider is stating on his office note to "see orders " under his plan of care and when I go to the orders he has Labs listed here, can I count these towards medical decision making? He does not specifically list what labs he was ordering on the actual note, just statement to see orders.

Thank you!
 
As long as the orders are part of the medical records, then I believe yes, they could be counted. I will note it's not a best practice to have multiple documents for a single service. Any EMR I've worked with will allow the order to easily be pulled into the note without the need for the provider to document everything twice. For a one off, I would count it and educate the provider for moving forward.
 
You must log in or register to reply here.
Top