Wiki Insurance audit - actual labs or will prgress notes

[sstlawre]

Physican has documented in patients progress notes that pt has positive antibodies. Is this sufficent to survive an audit by a commerical payer or are actual labs needed to validate?

 

[pclaybaugh]

I would say that the progress note should stand alone. The physician based his findings on lab results. I assume that this is a denial and just submit the note.