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dfincher

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Texarkana, AR
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I have a question concerning one of my doctors. He is behind on his dictation. He is wanting to fill out a E&M sheet, sign it. also he is wanting to use the patient questionnaire as the ROS. so it would be the Patient Questionnaire on one page (that the patient filled out) and the Exam, MCM and findings (on another sheet). He then wants the office to scan it into the patients chart. Then he wants me to code and bill to the insurance company. He is wanting to do this only to get caught up.

My question is this okay for him to do. I told him I wasn’t for sure about the patient questionnaire. Any help would be greatly appreciated.
 

jimbo1231

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Brooklyn, New York
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Timing Issue?

I'm not certain I understand some of the question. Is your concern that the doc wants you to code prior to his completion of dictation which he is behind on? If so, you can't code if no documentation besides the super bill is completed, even if he checks a level. If you are coding based on actual handwritten and signed documentation that is scanned in that should be OK . However, I would be concerned if the late dictation conflicts with the documentation you are scanning in. An ROS questionnaire is OK, but he must review and sign off on it. Jim
 
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