Wiki Venipuncture billed but nothing in the documentation other than a second superbill form

[nancy726]

Good Afternoon, I have a provider who is billing for a venipuncture but it is clearly not indicated in the chart note. There are two separate superbills, one for the office visit, PVR and UA and a separate superbill for the venipuncture.
Is this okay from an auditing view point?
thank you,

 

[thomas7331]

Anything that a provider bills needs to be documented in the patient's medical record, and signed and dated by the individual who performed the service. A superbill is just a communication tool between the provider and their billing department - it's not considered part of the medical record so in most cases would not be sufficient.