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Auditing office notes

  1. #1
    Default Auditing office notes
    Medical Coding Books
    I have been auditing hospital notes for about a year now, so that is what I am used to doing. They are much easier to do, because all the notes are dictated. However, I am beginning an education process with a group of new physicians that are office based. Of course there is not as much documentation in these notes and the Physicians are marking high level codes. My question is:

    I have received the office note to audit, as well as a letter thanking another Physician for the consult. In this letter he listed his assessment and other information that could be useful for auditing. I am going to say I can't use this information as the audit, but I want to see if anyone else can give me some tips on auditing office notes.

    Tiffany Fischer, CPC, CEMC

  2. #2
    Milwaukee WI
    Default Why can't you use the documentation?
    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

  3. #3
    Swainsboro/Statesboro, GA
    Default I would use all documentation
    I agree with Tessa in her comment of using the letter in your audit. I would use everything available. Also, if I understand your post, you are auditing a consult and that letter to the primary physician is a requirement for billing a consult.

    In my opinion, having an effective and understandable audit tool is most important in auditing all documentation. There are many tools available for auditing E&M services, but it is very important to use a tool you can understand.

    Good luck!
    Freda Brinson, CPC, COC, CEMC
    AAPC Swainsboro/Statesboro Chapter
    2017/2018 Secretary/Treasurer
    2016 Education Officer
    2014/2015 President
    Past President - 2012, 2008; Past Vice President - 2013, Past Education Officer - 2009 of Savannah, GA Chapter
    Past Member AAPCCA Board of Directors (2009-2012)

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