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Wiki documentation

monalisa

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49
Location
Chicopee
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Hi Everyone,
I am wondering if you can help. I have a doctor who does not like to write a lot so on his gyn forms he has a section in which he just has a few words and we are wondering if that is would qualify as documentation for doing a bladder pressure study, Biofeedback.
This is what it looks like
Bladder S/S
1 = Incontinence
2 = Nocturia
3 = Frequency
4 = Urgency
Then he will check one of these if it applies to the patient and wants to bill a Bladder pressure study. Is that enough documentation to support billing this?
I do not have much experience in E/M Chart documentation. That is next on my list to learn and earn that credential. So if anyone could help me that would be great.
 
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