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E/M question about 1995 guidelines

  1. #11
    Woodland Hills, CA
    Medical Coding Books
    This is what I just read about the line;
    "Use of a checklist or template is acceptable. If a checklist is used to document the examination, written descriptions with positive or negative findings should be documented for any area or system related to the problem or complaint. Using a line drawn down a checklist is not sufficient unless the documentation very clearly defines the exact system and area examined. Most coders and auditors will advise physicians and physician extenders not to use lines but to define the area or system examined more clearly by using a check mark or circle".
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  2. #12
    Duluth, Minnesota
    yup... I'd agree with that completely. It's neither right or wrong, it's advised against, and it's not liked by coders or auditors... but in the end, after it's all said and done - it can be done that way. (line-through) documentation supporting of course.
    Donna, CPC, CPC-H

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