jennyannk73
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STRANGE question regarding E/M documentation
Doing some audits I stumbled upon something strange and I need some backup.
A gastroenterologist in our practice saw a patient in our office on 3/30. This patient was scheduled for a colonoscopy (hospital outpatient) and our doctor dictated, at the hospital (to avoid transcription costs here), a pre-op history and exam note that says at the top:
Date Transcribed: 3/30/10
Date of Service:4/08/10.
I randomly chose to do an audit on the office visit for 3/30/10. Because the above note, transcribed at the hospital does not have a DATE OF SERVICE of 3/30/10, I failed him for this audit. After much discussion I was told that I was wrong, that there was no way that he shouldn't be able to use this note because it was transcribed on 3/30/10. As much as I would actually LIKE to be wrong this time, I really don't think that I am. Am I misguided here? Of course i'm going to be required to prove my point, but I would think that if an auditor does not find a note with the correct date of service listed that this would be a big problem. Any advise appreciated!
Thank you,
Jenny
Doing some audits I stumbled upon something strange and I need some backup.
A gastroenterologist in our practice saw a patient in our office on 3/30. This patient was scheduled for a colonoscopy (hospital outpatient) and our doctor dictated, at the hospital (to avoid transcription costs here), a pre-op history and exam note that says at the top:
Date Transcribed: 3/30/10
Date of Service:4/08/10.
I randomly chose to do an audit on the office visit for 3/30/10. Because the above note, transcribed at the hospital does not have a DATE OF SERVICE of 3/30/10, I failed him for this audit. After much discussion I was told that I was wrong, that there was no way that he shouldn't be able to use this note because it was transcribed on 3/30/10. As much as I would actually LIKE to be wrong this time, I really don't think that I am. Am I misguided here? Of course i'm going to be required to prove my point, but I would think that if an auditor does not find a note with the correct date of service listed that this would be a big problem. Any advise appreciated!
Thank you,
Jenny
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