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Record documentation

  1. #1
    Default Record documentation
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    I have a provider that performs pacemaker evaluations in the office. Sometimes, he may do an evaluation and management service in conjuction to the pacemaker check. Here's my dilemma. He may order a complete metabolic panel and TSH but never dictates the reason why he's ordering these test. My guess is because the patient has been on high risk meds for some time. Before I would modify his claim, shouldn't he dictate his reason for ordering the test in order to be counted for billing the separate EM service to the other procedure?

    Thank you all for your time.

  2. Default
    Yes, you are absolutely correct! Necessity to have these blood tests done should be documented. I believe these lab tests have their own NCD lists; how else can you provide a billable dx if it is not in the chart note?

    Dolores, CPC-CCC

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