Wiki Documentation

[jsturgeon]

Patient goes to hospital for evaluation/observation and phone orders are called in, however MD may never see patient. The hospital nursing staff will write phone orders in the chart and the physician will sign off on them. Does this qualify for a bill???? I have no notes that the MD saw the patient only phone orders. I have not been billing, based on what I've been told. No documentation it didn't happen. Does phone order qualify for a bill???
Please help with this...
Thanks

 

[Lisa Bledsoe]

I don' think so. In order to report an observation code you have to meet all 3 key components, which would obviously require an exam by the doctor.

 

[racheleporterwilliams]

response to documentation

no physician exam in the hospital...oh my!!
yes, this case can not be billed

Patient goes to hospital for evaluation/observation and phone orders are called in, however MD may never see patient. The hospital nursing staff will write phone orders in the chart and the physician will sign off on them. Does this qualify for a bill???? I have no notes that the MD saw the patient only phone orders. I have not been billing, based on what I've been told. No documentation it didn't happen. Does phone order qualify for a bill???
Please help with this...
Thanks