Services performed in the office are generally marked on a patient's encounter form by the:

administrative medical assistant

When records are reviewed by third-party payers, if a procedure is not documented, it:

is considered to never have been performed.

will be reimbursed at only 50% of the standard rate.

must be resubmitted with a statement of explanation from the provider.

will be reimbursed at only 10% of the standard rate.

Chapter 28: Procedural and Diagnostic Testing

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