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[cingram]

Ok so at my job the doctors see patients at the hospital but the hospital does not requre the doctors to dictate their follow up visits. I do not feel comfortable coding with no documentation and will not do it. is there any websites that you guys have that can help me present something to the doctors on why they need to do it and what can happen if they dont?

 

[jackson7591]

Reference

http://www.trailblazerhealth.com/Publications/Training Manual/EvaluationandManagementServices.pdf

Page 6 point 4 states "documentation should support the level of services reported.". As
I'm sure you know, no documentation, nothing to report.

 

[FTessaBartels]

Documentation does NOT equal Dictation

The progress notes CAN be handwritten. They do NOT need to be dictated. A handwritten note is billable (as long as you can read it and abstract the appropriate level of service).

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[akrug]

At my previous office I would have to request the chart notes from the hospital for the dates the doctor said he saw the patient. It took a while to get the notes but at least I had something to go by.