Wiki H & P, Is this billable?

abrodskycpc

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Hi all,

I work for an Ortho who was on call at the hospital. He was called into the E/R and decided to take a patient into emergency surgery after he assessed them.

He handwrote a "Short for history and physical" and there is no dictation. He wants to know if this is billable?

Since this was the decision for surgery, I think it is billable.

If so, how do I do an E/M audit if its just on a fill in the blank for.

Thanks!
 
The assessment must be over above and beyond as assessment of the affected area to be billable. Without the note I can't say, but from what you have indicated it does not sound like the assessment meets the criteria of significant and separately identifiable.
 
The assessment must be over above and beyond as assessment of the affected area to be billable. Without the note I can't say, but from what you have indicated it does not sound like the assessment meets the criteria of significant and separately identifiable.

It is literally just a fill in the blank/checkmark form that the hospital provided him. I just wasn't sure if it would be billable because that is where he made the decision for surgery.

Typically when I see something like this, I would not consider it billable.
 
A check form?? No not a billable E&M.

That is what I thought, I just wanted to be sure.

It looks like a checklist of things he discussed/went over before surgery.

For example:

- Nursing/medical/social administration history reviewed
-Current medication reviewed
-labs reviewed

Physical exam:

Heart, Lungs, HEENT...etc are all check marked as normal.
 
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