I really need some serious input here. Been returning NP documentation to the physicians due to the MDM I feel does not meet the level of E/M they have chosen. I am getting them back with notes to charge anyway. Second if it is a Workers Comp claim where we have to attach the notes and the assessment/diagnosis or the number of x-rays taken of say the knee are not stated in the documentation I am being told by the physicians to attach the encounter/super bill because it is marked on there. I know I am fairly new at this, but is that acceptable. My stomach is churning. Also, I had told one of the physicians that afebrile is not acceptable when part of the vitals again I was told that the actual temp is in the patient EHR and can always be access for that day. Is this correct also. SO CONFUSED Thank you for listening.. AJ Unsertain
Ill Feeling/E/M Coding
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