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