I have a doctor that dictates his consults with a one line history of present illness and a very short plan and the P.A. does an extensive consult. Does the doctor need to dictate more extensive or can we base our code on the P.A. and the little the doctor dictated? The plan indicates a heart cath is planned. Also, in the office his dictation is very short. He does have the day sheet that he makes notes on and signs the bottom. How much of that can we use in conjunction with his dictated letter?
Thank you for your help.
Thank you for your help.