I'm not sure I understand your question.
Why can't you use the documentation provided to audit the service?
I've seen cases where for ONE visit there is a patient intake questionaire, a hand-written (consulting) physician exam template, and then a letter to the physician who requested the consult that gives a summary of the consultant's findings and the recommendation.
As long as all three items are cross referenced and presented as support for the code assigned, you can use all three.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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