Wiki Lacking components

[maine4me]

Okay, I am currently auditing a note for an new patient visit from our Infectious Disease Practice. When I look at the note I do not see anything that would be considered medical decision making, no assessment or plan. If this element has been omitted from the note is the visit billable?

Also, for history there are only 3 elements of HPI, 4 systems for review of systems, and 1 system in the exam.

 

[FTessaBartels]

Please post the note

Please post the scrubbed note. Without seeing the documentation I can't begin to tell you what to do.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Evelyn Kim]

the note would be helpful, however for the first part if this is a new patient and the note does not contain all the needed elememts you can revert to an established visit that only requires 2 of 3 elements to assign.