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Wiki Not meeting admit levels for inpt

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raidaste

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I have a physician that admitted a patient to the hospital after seeing them in the clinic. They filled out out H & P form but it in no way meets the documentation requirement for the 99221 detail or comp. If he was not the admitting then I could charge a subsequent but is it the same for this situation. Since he's the admitting physician is there an e/m I can charge for the admit day.
I thought of using the office note too but it doesn't give me added info. What, if any, can be charged for this admit day?
 
some payers will instruct you to use the subsequent level, this is what medicare states, and others will say to use the unlisted E&M code. Was the provider informed that minimal documentation had not been obtained?
 
Yes, he's been told before the requirements previously. He's done usually well since I've taken over and so I don't ever run into this problem but this one confused me.
Also this particular patient was a post surgical patient w/in the global period and had developed cellulitis and was admitted for IV antibiotics. So now I'm wondering if I can bill anything at all for this stay since it was a postop infection. :(
 
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