A patient came in to PCP’s office to do a urine sample- the MA did a urine dip. They billed for 81002 but I do not have documentation by a nurse or doc indicating the patient was here…. I know the patient was because the results are in chart. My question is are the urine results proper documentation to support billing 81002? At my previous practice the MA always did a note with why patient coming in for urine sample and what physician was in the office…etc. and included the results. Newer to auditing and needing some advice. Thank you!