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Vaccinations

  1. #1
    Default Vaccinations
    Medical Coding Books
    I am auditing a chart and the physician does not mention on the medical record that pt is to receive a Flu vaccine however; they provided me with a vaccine administration form and the immunization records.

    My question is: Does the physician need to document on the office visit note that pt is to receive the vaccine today????

  2. #2
    Smile
    YES...If not documented, not done......

  3. #3
    Location
    Daytona Beach
    Posts
    40
    Default
    I agree- it has to be requested by the Dr. Any procedure, injection, or diagnostic test must be recorded by the Dr.

  4. #4
    Location
    Overland Park, KS
    Posts
    1,166
    Default
    I totally agree. There must be documentation to support the vaccine. Otherwise, it can't be coded/billed. Thanks.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow
    Coder

  5. #5
    Default Vaccinations
    That is what I thought, thanks for confirming it.

    Thanks

  6. #6
    Default Vaccinations
    Ok I have one more question, I need to find reference material to provide to the MD. I have read somewhere that it must be ordered and I can't find it. Do you know where I can find "written documentation" to support this?

    Thanks for all your help

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