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Consults for Commerical Insurance

Nancy Posted Fri 01st of April, 2011 15:46:49 PM

Please help with this discussion. I have a Spine Specialist when he does a consult in his dictation he states Past Medical Hx: Has been reviewed and is signed in the patient's chart
Past Surgical Hx: Has been reviewed and is signed in the patient's chart
Family Hx: Has been reviewed and is signed in the patient's chart
Social Hx: Has been reviewed ans is signed in the patient's chart
ROS: has been reviewed and is signed in the patient's chart.
When he states is signed he means the patient has signed the forms. My question is; Is this appropriate documentation for a Level 4 New Patient Consult?
Thanks for your help

SuperCoder Answered Fri 01st of April, 2011 20:48:30 PM

Does the comment "Has been reviewed and is signed in the patient's chart" tell you how many elelments have been documented, the severity, the treatment options taken...etc. The answer is "NO".

This is not a proper E/M documentation.

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