Wiki E&M Level Coding in a RHC (Rural Healthcare)

[kschulte71]

I need guidance please.
We have a patient that was seen in the RHC clinic. The MA documented in the chart the social history, the Vitals, an a med reconciliation. The doctor circled a level 3 on the superbill and added a diagnosis code; however, he never did any documentation himself (no dictation or entry into EHR). The superbill is signed and has the dx code on it. It also states on Superbill that it is part of the medical chart and scanned into the chart. Would this visit qualify for a Level 2 visit based on the MA documentation and the Superbill?

 

[mitchellde]

I need guidance please.
We have a patient that was seen in the RHC clinic. The MA documented in the chart the social history, the Vitals, an a med reconciliation. The doctor circled a level 3 on the superbill and added a diagnosis code; however, he never did any documentation himself (no dictation or entry into EHR). The superbill is signed and has the dx code on it. It also states on Superbill that it is part of the medical chart and scanned into the chart. Would this visit qualify for a Level 2 visit based on the MA documentation and the Superbill?

No it does not qualify as a chart note. The chart note must be written by the provider or it can be written by a scribe. So unless the MA was acting as a scribe and identified as such then it would not be appropriate to use the MA note.

 

[kschulte71]

Thank you.