Blank physician t-sheet

[QuadRider]

Can a hospital facility coder charge for any E/M level if the physician t-sheet only has a dx & signature on it? There is no HPI, ROS, Physicial Exam or anything done. Only a dx. And he did write an RX. Not noted on the t-sheet.

 

[JulesofColorado]

Do you have a dictation? If not, I would request the provider to complete the T-sheet and dictate a report before coding.

 

[QuadRider]

No dictation sheet. Will request completion of t-sheet. I realize that being a physician coder, I can't charge until documentation on physician t-sheet is complete, (no exam done unless documented). I used to be a facility coder, needing a reminder of facility charging though for the hospital I work with. Thank you for your input always

 

[jimbo1231]

You can code on the facility side but....

You don't need physician documentation for a facility level. So if this is a patient who was triaged and left or a similar scenario, the blank T-Sheet makes sense. But if the patient was treated by the physician, the T should ibe returned for documentation for medical legal reasons as well as coding the physician services.

Jim