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Chart Audit Question

  1. #1
    Default Chart Audit Question
    Medical Coding Books
    My doc has billed a consult and meets the criteria for that. However, for documentation purposes is it necessary for the referring doc's documentation to also be in the patients chart.

    Thanks

  2. #2
    Default
    Quote Originally Posted by TAMMYS View Post
    My doc has billed a consult and meets the criteria for that. However, for documentation purposes is it necessary for the referring doc's documentation to also be in the patients chart.

    Thanks
    The referring doc's documentation should support that he/she referred the patient, for what, and to who.

    It is not a requirement that you have their documentation in the chart. (Though physicians like to) An auditor would look at your consultation, see who referred the patient, and if necessary he/she can go back to the referring doc's notes to make sure they indeed referred the patient.

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