Sarah Ann
Networker
A pt. comes in for knee pain- In the HPI, exam, assessment/plan there is only documentation related to the knee pain. Denial for a covid 19 test because the Z code was missing. It was missing because there was no mention anywhere in the encounter HPI, exam, MDM assessment/plan that they were doing a covid 19 test. There is a separate tab for the DOS to look at orders There was an order for the covid 19 only. Does that suffice as documentation? I would think that info. would need to be in the assessment/plan OR somewhere in the note on that DOS. Opinions??