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One of our general surgeons chooses to see every patient after a procedure has been done. Instead of an office note he simply does a letter to the referring physician, he then wants to bill (if appropriate) from the contents of the letter. Can this be done or should he be making a "chart note" along with the letter he sends?


It is good policy for the surgeon performing the procedure to see the patient at the first visit after the procedure. We are assuming that the surgeon dictated the letter. The surgeon should be making a chart note in the medical record. This chart note may be dictated, but the documentation in the chart note should be the basis of the level of service billed. The chart note can then provide the basis of a formal letter to the referring physician. You can also send a copy of just the chart note to the referring phyisican rather than having the surgeon dictate another document. However, a letter makes the best impression on the referral source.

Mary Beth Black, CPC
Senior Associate

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