Banner

Complete the Record

Article

If a physician checks or writes a diagnosis on a charge ticket but didn’t note the diagnosis in the medical record, can the biller code the diagnosis that is on the charge ticket? Is the ticket a sufficient record for billing?

Question: If a physician checks or writes a diagnosis on a charge ticket but didn't note the diagnosis in the medical record, can the biller code the diagnosis that is on the charge ticket? Is the ticket a sufficient record for billing?

Answer: According to Susan Callaway, CPC, the charge ticket is not sufficient documentation. It is not part of the medical record; the diagnosis must be in the record. The physician can make an addendum if needed.

Recent Videos
Practice lessons from the works of Mark Twain
Practice lessons from the works of Mark Twain
The three stages of a physician's career
Using AI agents
Jennifer Wiggins
The three stages of a physician's career
Using AI agents
Jennifer Wiggins
Resurrecting the handshake
Jennifer Wiggins
Related Content
© 2025 MJH Life Sciences

All rights reserved.