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H & P, Is this billable?

abrodskycpc

Networker
Messages
37
Location
Aurora, Illinois
Best answers
0
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!
 

mitchellde

True Blue
Messages
13,296
Location
Columbia, MO
Best answers
0
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.
 

abrodskycpc

Networker
Messages
37
Location
Aurora, Illinois
Best answers
0
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.
 

abrodskycpc

Networker
Messages
37
Location
Aurora, Illinois
Best answers
0
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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