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Documentation Question

  1. #1
    Default Documentation Question
    Medical Coding Books
    For the examination our providers have added the notation 'unchanged from the previous visit' to the templates. Don't they have to document the examination again?

  2. #2
    Location
    Tacoma, WA
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    Quote Originally Posted by loulou87 View Post
    For the examination our providers have added the notation 'unchanged from the previous visit' to the templates. Don't they have to document the examination again?
    Yes, because how else do we know they actually examined all the same areas as the last visit. It is possible not as many areas were examined, or that more areas were examined.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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