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Wiki Question re E&M coding

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Chelsea1

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We use a EMR system and not all information is documented on the visit note by the doctor when I audit the note. However the letter to the PCP regarding that visit is. My question is, can I combine both notes to use in coding the visit out?

Thanks
 
That is an interesting scenario. Looking at this from a coding point of view if the letter to the PCP is part of the documentation of the patient's chart then it can be used to level a claim. The guidelines state that the service should be noted in the patients records, but it does not define what format that record should take.

However, with that said, from an auditing point of view it raises concerns that complete documentation is not being addressed on the progress note of the chart and could have a financial impact depending on the payers point of view on this grey area. I would address this issue with the provider as a red flag from an auditing and coding point of view. This is definitely a concern that the provider is sending a summary to the PCP indicating either history, exam, or MDM that was not clearly documented on the physician progress note for the date of service.
 
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