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  1. Default Documentation
    Medical Coding Books
    Ok so at my job the doctors see patients at the hospital but the hospital does not requre the doctors to dictate their follow up visits. I do not feel comfortable coding with no documentation and will not do it. is there any websites that you guys have that can help me present something to the doctors on why they need to do it and what can happen if they dont?

  2. #2
    Default Reference

    Page 6 point 4 states "documentation should support the level of services reported.". As
    I'm sure you know, no documentation, nothing to report.

  3. #3
    Milwaukee WI
    Default Documentation does NOT equal Dictation
    The progress notes CAN be handwritten. They do NOT need to be dictated. A handwritten note is billable (as long as you can read it and abstract the appropriate level of service).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    At my previous office I would have to request the chart notes from the hospital for the dates the doctor said he saw the patient. It took a while to get the notes but at least I had something to go by.

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