tci Medicare Compliance & Reimbursement - 2013 Issue 16

Reader Question: Your Physician Has Various Ways to Document

Question:  My ob-gyn reported an established patient office visit code 99214, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. The doctor insists that this is the way he has always done things, and there has never been a problem before. Is this acceptable? It doesn’t seem right to report a code without a standard progress note format. Answer: There are no specific guidelines for what a provider’s documentation must look like, only what elements must be included in order to achieve a code level...

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