inpatient subsequent visit


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in a teaching hospital facility so for a subsequent inpt hosp visit the physician is not writing a linking statement. due to that the resident/fellow note is unusable but he/she is writing a very, very brief interim history, saying exam is unchanged and then writing the a/p
should this be unbillable bc it cant be proven that the doc actually saw the patient or not or do i just go w/ the 2/3 hpt and mdm?

Government payor or commercial?

If the patient is covered by a government payor (Medicare, Medicaid, etc), then the physician in a teaching hospital MUST indicate that s/he personally attended to the patient. If there's no evidence of face-to-face contact the service is not billable.

If it is a commercial payor, go with the 2 of 3 rule for your level of subsequent hospital visit.

Why isn't he writing a linking statement to the resident/fellow note? That would be usable in Wisconsin for Medicaid, as well as all commercial payors. Sounds like this physician would benefit from some compliance training.

F Tessa Bartels, CPC, CPC-E/M