AAPC - Back to school
Results 1 to 2 of 2

Thread: Documentation from a form

  1. #1
    Join Date
    Apr 2007
    Lansing, Michigan

    Question Documentation from a form

    AAPC: Back to School
    I was reviewing one of my doctor's charts and he noted "form completed" in his progress notes. When I reviewed the form I found information on the form that was not in the progress notes. Basically history information. I think my question is simply - can the information on the form be part of the documetation for the E/M code? when it is not in the actual progress notes? Thanks.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default NOT ideal reference

    "Form completed" isn't an ideal reference, but if it's all done on the same date of service and the form is clearly signed/dated by the physician, then, yes, I'd count it.

    A better documentation on the progress note would be: "Patient history form completed and reviewed by myself today. Please see form in chart for additional details."

    It only takes a few seconds for this "better" documentation, and it helps to make the progress note "audit proof."

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Vanderbilt form
    By cperk in forum Behavioral Health
    Replies: 0
    Last Post: 12-03-2015, 10:23 AM
  2. 1500 form 8/05 vs 2/12
    By slauchart@msn.com in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 04-22-2014, 12:25 PM
  3. Documentation on correct documentation placement of procedure notes in the EMR
    By ashephard in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-25-2014, 03:36 PM
  4. 5 A's form
    By Cottrell in forum Medicare Regulations
    Replies: 3
    Last Post: 01-03-2012, 06:20 AM
  5. Ub 4 Form
    By Alisha Lemmons in forum Behavioral Health
    Replies: 2
    Last Post: 02-26-2009, 10:48 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.