The order for it to be done and why it was done should be in his notes and then it can be billed. The MA shouldn't be doing it without an order from him so that might be in the record already. It's good documentation and to his benefit to document the results. He should refer to the results to show that he saw it and if he did anything about it. He could refer to where they are in the chart or electronic medical record and give his input or he can reiterate the actual results in his note. When he documents that he ordered it and/or reviewed the results, it counts towards his level of E/M under the medical decision making portion.
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