Wiki Free Text documentation

[tls081964@yahoo.com]

My provider continues to document only a free text documentation and expects us to code it and get paid. I don't feel there is enough information. Any input would be appreciated.

 

[sls314]

My provider continues to document only a free text documentation and expects us to code it and get paid. I don't feel there is enough information. Any input would be appreciated.

This patient is in the hospital, correct? "Likely home tomorrow after wound teaching" implies to me that the patient is in the hospital.

My answer below is assuming that the patient is in the hospital, and that you snipped out the header and footer with the patient information, the date of service, the facility name, and the signature for privacy purposes. (If the documentation isn't signed or doesn't have the patient information, disregard what I say below.)

You have enough information to code a hospital visit. You have a diagnosis, a medically appropriate exam, and an assessment/plan.

The provider uses a lot of abbreviations, but the exam and assessment are fairly detailed.

It definitely looks like an "old school" note, and you're probably used to seeing prettier templates from other providers. However, you have the components necessary to level a hospital visit based on medical decision making.

 

[carlystur]

Yes, I often see hospital follow-up notes like this from our providers as well. I code them normally.