Wiki If we have Virtual encounter note in a telephone encounter, can we add an office note for billing purposes.

[MrsBrendaAlbis]

We had a doctor do a telephone encounter and wants to also add an office visit note for billing purposes in the telephone encounter for billing purposes. I advised doctor to do a regular office visit note in the chart. I didn't think that an office note could be added to a telephone encounter for audit purposes. Please advise.

 

[sls314]

We had a doctor do a telephone encounter and wants to also add an office visit note for billing purposes in the telephone encounter for billing purposes. I advised doctor to do a regular office visit note in the chart. I didn't think that an office note could be added to a telephone encounter for audit purposes. Please advise.

Do you mean a note for the telephone encounter? Telehealth visits should be documented too, so creating a telehealth phone (audio) visit note would be fine.

If he's wanting to create an office visit note that misrepresents the encounter as though the patient was in office, that would not be okay.