suzybeth2002
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We have spent most of this year trying to educate our physicians on the proper way to document consults and office visits. They have improved somewhat, but some of them argue this point about the physical exam. Documentation requirements are for a certain number of elements identified by a bullet. Some of our doctors say the elements are just examples, and they can document anything in the body system or body organ. My understanding is that it has to be the specific element listed. Is there anything in writing that clairifies this question?