I don't think that she can add anything "after the fact" now but maybe let her know that in the future, even documenting what she said about "refer to last documentation" would be better than nothing. Every report does have to stand alone and you are right there. When in doubt, query the physician. If they want to be reimbursed properly, then they should listen to what you have to say about the matter. If only the physicians could see how much proper documentation can help with reimbursement, I'm not sure that they realize just how important it is sometimes!! It can ocasionally come down to only a few sentences or just asking the right questions and documenting them. Only in a perfect world, huh?!
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