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Thread: DOCUMENTATION please help!

  1. #1

    Question DOCUMENTATION please help!

    AAPC: Back to School
    My doctors seems to disagree with me on documenting
    pulse oximetry in doctor's dictation. The MA had written down
    in chart pulse ox and the rate.
    example: pulse ox 197

    But the doctor did not have it in his dictation. I mentioned it to him to do addendum to include the pulse ox so we can bill it. But he responded "No I don't have to have it in my dictation as long as the MA documented in chart it is ok " To my knowledge everything has to be dictated by the doctor in his dictation. Am I right, or was he right? I need to let him know the fact.

    Thanks in advance

  2. #2
    Join Date
    Apr 2007


    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.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I
    AHIMA Approved ICD-10-CM/PCS Trainer
    AAPC National ICD-10-CM Trainer

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