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Pain Management documentation

L

LaSandra

Contributor
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22
Location
Fort Worth, TX
I have a pain doctor that is wanting the M/A to type the radiology impression (findings) from another facility's radiology report on the patient's visit word for word, is this ok to do according to the standard documentation guidelines.
 
I would like to know the answer to this as well.



LaSandra said:
I have a pain doctor that is wanting the M/A to type the radiology impression (findings) from another facility's radiology report on the patient's visit word for word, is this ok to do according to the standard documentation guidelines.
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Reply to Pain Management documentation

There is no issue with typing the radiology report into the note. In the EMR, the radiology reports are pulled into the physician note all the time.

The issue would be how you would count this into the E and M. If it is just typed and the provider does not indicate review of the findings, then I would hesitate to credit towards data.
Even in the EMR, some organizations require the provider to indicate review of the radiology report.
 
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