Wiki E/M in letter form

[justkiminnc]

ALL our office visits are dictated in the form of a letter to the PCP (or requesting physician). Whether they are a "consultation" or not. Does anybody know where I can get this in writing, that this is allowed for auditing reasons?

 

[sbicknell]

As long as the documentation captures all the requirements to support coding the E&M level and any procedures, then the format (letter, SOAP etc) is irrelevant as far as auditing.

My experience is that the referring physician is not interested reading a 3 page letter with PFSH, exam etc on their own patient. They want the nitty-gritty meaning MDM and maybe HPI. Anything more than 1 page is usually not read.

Usually the referring wants to know 3 things
what's the Dx
plan of care
any med changes

My 2 cents.

 

[justkiminnc]

Thanks, that what I thought but I couldn't find it in writting anywhere that said it was ok. I'll keep looking.

 

[FTessaBartels]

ALL our clinic notes are letters

Our surgeons dictate ALL clinic notes as letters to the PCP or requesting physician (depending on the nature of the visit).

They usually start with a summary paragraph that includes their findings and recommendation, and then continue with the complete history, exam, assessment/plan. This lets the PCP stop reading after the first paragraph if s/he is so inclined, and still get the needed info.

You are not going to find anything in writing, Kim, that tells you that this is specifically okay. Your code should be assigned based on the elements documented, no matter how they're documented or in what order.

Hope that helps.

F Tessa Bartels, CPC, CEMC