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Wiki notes

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WFassnacht

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I am trying to get some help with professional billing for E&M. Do any other professional coders go and look at orders in order to bill a service?
I am being told i should review the note and orders but with E&M's i have been trained the note has to stand alone
Thanks
 
If the orders were placed during or as part of the assessment and decision making, then yes, we do review the orders.

When you are looking at the records in the EMR are the orders from that days visit not tied into the medical records for that date?
 
I have an order for Telemetry monitoring but was ordered a day later 2/5 but on my progress note on 2/4 itself there is no mention of telemetry monitoring being ordered for the patient. We have different tabs in our EMR that we are able to click on and see the orders.I again with my training if it is not documented on the note I would not even know to go and look at the orders. Please any feed back from anyone would be helpful.
Wendy
 
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