Help with E/M Documentation Question

[tinaleslie]

I have a hospital provider that completes a separate chart for an initial visit but has started listing a summary of each subsequent visit under the date of the discharge. He gives a short summary and a little decision making. When I review the charts I am seeing it a a summary of each day. Not a visit.
There are no exams with these. The CPT guidelines state, "E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed." I interpret that it doesn't necessarily have to have an exam. But does each chart have to stand alone with date and signature or can he do a running summary of each day on one chart.

Example looks like this

1/10/23
Seen today on dialysis
-Patient to start regular physical.
-asymptomatic
-Awaiting for cardiology/EP consult eval
-Awaiting podiatry consut
-Awaiting for diabetic educator eval
-No chest pain or trouble breating
-No nausea or vomiting
-Foley catheter removed
-No trouble with urination

1/11/23
-Complains of nausea
-Has diarrhea
-ad dialysis last night
-No trouble with urination after Foley catheter removal
-On MiraLax as needed
-Not seen yet by EP and will put an order for second request
-Seen by podiatry and they will clip tonails hopefully today
-During writng my note I was called by his nurse that his diarrhea smelled like C.diff and will collect stool for C.dfficile PCR
-also we may get GI panel, second request


Its a running note. Can they be billed separately? (I am stating no, but change my mind?)

 

[kayleeevans907]

Just from the info here I'm inclined to say no.
I can't identify what the patient is presenting for or what the provider is assessing/treating in the first note (1/10/23). The second note I could pull nausea & diarrhea as dx codes and see that they're using OTC meds (miralax) for treatment so based on that I guess you could try to use MDM but I dislike that there isn't much specifically about the condition in relation to the patient (how long has the nausea & diarrhea been present? is it made better/worse by anything?).