There is no rule on how a note has to be laid out. As long as the elements are there you can count them regardless of where they are physically located in the note.
It is much easier for the person reading the note after the fact, from both auditing and clinical points of view, if there is structure to the note so you might try and talk to the provider about that. Maybe get them a template to help organize their dictation or hand written note, whatever the case may be.
On days like today, I would be happy for any elements of exam anywhere, lol.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join