Deal Or No Deal Template Page 4
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31Documentation Elements (Cont.)
• Medical Decision Making
– No diagnosis
– Unclear diagnosis – HA, HTN, DM
– No status
– Medical necessity for diagnostic tests
(rule-outs ok – but not on claim form!)
– No plan of care/follow-up treatment
– Failure to document prescriptions
prescribed or sample prescription
drugs given to patient
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Parent category: Life