RABBIT2020
Networker
A patient with no history of smoking or drinking presents to the emergency department for vaginal bleeding. By diagnostic she was found to be pregnant and evaluated and treated for this condition.
Provider documented the note to reflect the presenting problem, tests were ordered and reviewed and patient was dc to obgyn care.
The provider who is a MD documented an attestation. No other mid level provider/nor resident saw the patient so an attestation was not required.
on the attestation had 10 mins smoking cessation.
Evidently there was no smoking history nor any notation on the progress note of the effects of smoking to this patient's presenting problem.
There was no documentation of what was discussed re: smoking cessation.
should the smoking cessation code be billed just for the 10 mins of smoking cessation time documented?
or
should this be sent to the provider for proper documentation?
I was told - do not question the provider's clinical judgement/decision that what was discussed in that 10 mins could have been second hand smoking to the mother and baby therefore it is billable as is.
Provider documented the note to reflect the presenting problem, tests were ordered and reviewed and patient was dc to obgyn care.
The provider who is a MD documented an attestation. No other mid level provider/nor resident saw the patient so an attestation was not required.
on the attestation had 10 mins smoking cessation.
Evidently there was no smoking history nor any notation on the progress note of the effects of smoking to this patient's presenting problem.
There was no documentation of what was discussed re: smoking cessation.
should the smoking cessation code be billed just for the 10 mins of smoking cessation time documented?
or
should this be sent to the provider for proper documentation?
I was told - do not question the provider's clinical judgement/decision that what was discussed in that 10 mins could have been second hand smoking to the mother and baby therefore it is billable as is.