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Chart Audit Question

  1. #1
    Location
    Long Beach
    Posts
    11
    Default Chart Audit Question
    Medical Coding Books
    Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
    Thank you!

  2. #2
    Location
    Garden State Chapter, Cherry Hill, NJ
    Posts
    23
    Default
    In the 1997 guidelines, under Amount or Complexity of Data, one of the documentation guidelines states:
    "DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as 'WBC elevated' or 'chest x-ray unremarkable' is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results."

  3. #3
    Default
    Quote Originally Posted by tnapora View Post
    Do you give credit for Lab and Xray that was reviewed at the time of the visit, but not documented? Lab and X-ray reports in chart with signature and date on the actual reports themselves, but again, nothing in the progress note.
    Thank you!
    Not documented, not done....
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. Default
    When a third party auditor reviews the chart what is normally looked for is reason for the procedure, a physician's order, a supporting diagnosis, the procedure report, and acknowledgement of that report either in the progress notes or on the report itself.

  5. Default
    I would only code if it is documented and diagnose by the physician in the progress notes.

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