Wiki letter to referring doc

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healing13

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Can a letter to the referring doc be used for E&M documentation?

I have a doc that when I asked for a copy of one of his e&m's sent me over a letter to the patient's referring doctor. When I asked if this was his only note, he told me it was.

Is this okay? It needs to be sent to the insurance to verify medical necessity on a surgical service...

thank you!
 
Maybe

Before we moved to EMR our specialists frequently documented their office visits as a letter to the referring physician. It saved them dictating twice.

As long as all the elements are present to support the level of service, it really doesn't matter what form the documentation takes.

That "as long as" though, is a biggie. If all the letter states is something like:
Dear Dr Referring
I saw your patient First LastName today for evaluation of hernia and we'll be surgically correcting this within the month.

Well, obviously that's not enough to support any level of new patient or consult visit.

As is true for virtually everything ... it all depends on the documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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