Forum - Questions & Answers

May 31st, 2011 - BETH1031

progress notes vs doc orders in in/patient setting

When doing billing for in patient billing. Do you HAVE to go by the progress notes only and if nothing is in the notes, can you go by the Physician orders with dictation. For subsquent visits can you use the Physician orders if they have nothing in the progress notes.

May 31st, 2011 -

re: progress notes vs doc orders in in/patient setting

Anything documented in the chart is fair game for coding, but I don't think you can meet minimum proof of a visit if there are only orders written and no documentation of actually seeing the patient.



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