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Patients over Paperwork - audit question

Best answers
Given the new E/M documentation guidelines allowing ancillary personnel to document various portions of the E/M visit, with the provider simply referencing a review, does the reviewer need to see/validate the existence of documentation outside of this visit documentation in order to validate the CPT billed for this visit? For example, the provider references documentation in a past note, does the reviewer need to see the past note in order to validate the CPT for this visit?

Evelyn Kim

Local Chapter Officer
San Antonio, TX
Best answers
It is always best practice to be able to see the document being reference. In fact I just discussed this with a client because I had disallowed the AWV because the required personal history form was not attached to the visit, among other findings.

In addition the portion documented by the ancillary staff should be part of the visit note. Most EMRs allow portions to be documented by someone other than the physician, an audit trail can be a useful tool in determining if the data was in fact entered. If it is a separate document then it needs to be attached to the visit, when auditing it should be included for the review if it was indeed a factor in the leveling of the visit.