pt was seen for laceration and sutures were put in. pt was in office for very long time; nurses documentation consists of 2 pages including each time they checked pt in the room, size of laceration, how many sutures, how incident happened, etc. there were no vitals taken. all documentation came from nurses who cared for patient. dr signed progress note and will not add any documentation. he was in the room and did put in the sutures; he even ordered labs and ct scan. this has been sitting on his desk for quite sometime and he will not add anything but wants me to bill a level 3. can you bill an e/m that doesn't have vitals or any dr documentation?