heatherwinters
Expert
Note 1
I have a patient in ICU, the doctor's entire note is subjective and at the end he wrote "Time Spent : 1 hour, 30 minutes greater than 50% of which involved counseling/discussion of code status with family", no examination.
Note 2
The day after the above note, again, subjective only, with note at the end
"Time Spent: 45 minutes grater than 50% involved counseling concerning end of life issues" and a separate discharge summary/death note.
How would I code day one and day 2?
I have a patient in ICU, the doctor's entire note is subjective and at the end he wrote "Time Spent : 1 hour, 30 minutes greater than 50% of which involved counseling/discussion of code status with family", no examination.
Note 2
The day after the above note, again, subjective only, with note at the end
"Time Spent: 45 minutes grater than 50% involved counseling concerning end of life issues" and a separate discharge summary/death note.
How would I code day one and day 2?