UA without documentation in the note

mrolf

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West Point, NE
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Physician saw patient for abdominal pain and vomiting. UA was performed but nowhere in the documentation is the UA addressed at all.
However in the chart there is a UA flow sheet with results of the UA. Are we able to bill this UA even though the physicians does not document??

Please advise. Thanks for any help.
 

rthames052006

True Blue
Local Chapter Officer
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York, Pa
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There should be some documentation that the U/A was ordered somewhere in the chart, is this an EHR chart/record?

I review the CERT reports on a quarterly basis and have seen where Medicare has requested refund for labs (of all types) because there was no order for it to be done. This includes the blood draw fee for those labs that are drawn by blood.
 
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