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Thread: Documentation

  1. #1

    Unhappy Documentation

    AAPC: Back to School
    EKG was performed same day as office visit, but was not linked to an assessment or results documented in the note, however, it was reviewed in the EKG portion of our EMR. Can this be billed without the documentation being in the office visit note?

  2. #2


    Why was it done?

  3. #3


    No reason specified. Patient may or may not be symptomatic or have history of arrhythmias, but nothing is documented, ie, pt has history of afib and currently taking Coumadin and is in normal sinus rhythm, but nothing states that confirmed with ECG or even that an ECG was done.
    Our EMR has a place for the ECG and you have to go to it in order to review it and that is where physician electronically signed it, just nothing documented in the office visit regarding it. I have asked providers to document results under an assessment so that the ECG or any ordered tests are linked to a diagnosis, but wanted to double check on this before repeating same request to providers.

  4. #4
    Join Date
    Apr 2007


    If it isn't documented it isn't done.

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