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E/M coding for ER when ER documentation is complete except for the exam part?

Yolanda Posted Wed 16th of November, 2011 04:23:36 AM

When coding ER E/M physician coding in Hospital. The physician has a completed documentation but only has vitals listed for the Physical Exam part. Am I able to only use this or should I give back to physician to complete?

SuperCoder Answered Wed 16th of November, 2011 06:54:49 AM

You need to have complete physical examination for documentation.

SuperCoder Answered Wed 16th of November, 2011 13:35:54 PM

Send back to physician to confirm if the documentation in the report is correct or if there is some missing documentation, then request for sending those info

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