Physician who uses "examination unchanged since last visit"?

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

Moderators: Shannon DeConda, NAMAS Moderator

Post Reply
Shoshana
Posts: 73
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Wed Sep 26, 2018 3:29 pm

I have a physician who wants to say "examination unchanged since last visit". When I look back on previous notes, there may not have been an exam for several visits as they all say the same blurb. Would you give any credit for this? He is a specialist; and I am sure there are not many changes as he is treating chronic illness. His vital signs are always from the encounter's visit.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Post Reply