Coding Corner Answer

In the end, the physician must remember that documentation has to speak for the visit. The documentation should be done as if the payer or auditor is standing in the examination room with the physician. If it is clear and concise, there should be no worries if the practice is ever audited.

If you have questions about documentation, contact Melesia Tillman, CPC, CRHC, CCP, at (404) 633-3777 or [email protected].