Good Morning,
I have 2 patients w/the same IM Doc that were both given Hemmocult cards. However, there is nothing in the Dr's chart note/dictation or a Nurse note that these were given to the patients. The only documentation there is, is the results of the tests.
For this type of test is the lab result enough documentation that the lab was done to bill for it?

I usually go with the 'if it isn't documented, it didn't happen' rule, but there is some disagreement within our office for this test.

Thank you!!