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jreisert

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Local Chapter Officer
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I have a coding scenario a physician dont want to dictate or do his report he believe what he wrote in the encounter form is enough to be coded. Like what they do during the old days. But can a coder really code that encounter without the report? Can you do that both in establish and new patient? Appreciate any help. Thanks
 
I have a coding scenario a physician dont want to dictate or do his report he believe what he wrote in the encounter form is enough to be coded. Like what they do during the old days. But can a coder really code that encounter without the report? Can you do that both in establish and new patient? Appreciate any help. Thanks

What exactly is written in the encounter form?
 
Chief Complain, brief HPI, brief ROS or sometimes no ROS because they said you can pull it from HPI, brief PE or sometimes PE benign then decision making giving pt meds, or order labs, x-ray or sometimes ct but most of the time just meds, labs and return after 2 or 4 wks.
 
Chief Complain, brief HPI, brief ROS or sometimes no ROS because they said you can pull it from HPI, brief PE or sometimes PE benign then decision making giving pt meds, or order labs, x-ray or sometimes ct but most of the time just meds, labs and return after 2 or 4 wks.

Technically, a "dictated" report is not required to be able to file a claim; handwritten notes are allowed. I believe the real problem arises when providers jot down just enough info to jog their memory for when they do actually dictate. If the elements provided in the written note are enough (and legible :) ) to support the LOS billed, there's not really a problem from a coding standpoint. Your clinic's internal policy may be that they have to dictate before the claim goes out...that needs to be addressed internally. There's no differentiation on this for new vs established patients.

Hope this helps!
 
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