I have a doctor that uses templates while he sees the patient and then uses these templates as "notes" when he dictates that evening. Here is my question. When he dictates his Review of System, he is only listing 3 to 4 yet his template is filled out with either negative or positive (with additional comments) for all 10 ROS. He billed a level 5 new patient visit due to some very serious problems this patient was having. Now, we are being hit with a pre-payment audit on this claim. Will the Review of Systems on his template cover the documentation requirements even though his "typed dication" doesn't cover everything? Or, should I tell him to make sure he dictates everything from the template to his actual "typed dictation"?
Thanks for any input.....
Thanks for any input.....