Wiki Using Physician Orders for MDM

[pediatrics]

Can you use physician orders for MDM when it comes to auditing for a level of service on an E/M? And there is no mention in the E/M under the impression/plan? I was always told that the note for the E/M needs to be able to stand on it's own to support a level of service.

For example, if there is no mention of xrays being ordered or labs or a patient being restrained in the E/M note, BUT there is an order for those items, you can use the orders, nursing notes to support the MDM/increase the level of risk.

If that is true, where is it written in the official guidelines?

 

[Naveen Rachagolla]

Unless it is documented in the medical record you cannot bill for those services or else your level will go down.