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Wiki Unspecified Lac Repair

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lschock79

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Olathe, KS
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If I have a chart that length of lac is not specified in notes (either by MD or nurse), but is specified in EMS paperwork, can I use the EMS documentation for facility procedure coding?
 
I would say no you can't use the EMS. The rule I follow is if the MD did not sign the source of information or state in his notes he reviewed it and agrees you can't use it for coding purposes, facility or pysician. Just like if a drug was given and not ordered on the physician orders you can't bill it.
 
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