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documentation question

  1. #1
    Default documentation question
    Medical Coding Books
    pt was seen for laceration and sutures were put in. pt was in office for very long time; nurses documentation consists of 2 pages including each time they checked pt in the room, size of laceration, how many sutures, how incident happened, etc. there were no vitals taken. all documentation came from nurses who cared for patient. dr signed progress note and will not add any documentation. he was in the room and did put in the sutures; he even ordered labs and ct scan. this has been sitting on his desk for quite sometime and he will not add anything but wants me to bill a level 3. can you bill an e/m that doesn't have vitals or any dr documentation?

  2. #2
    Greeley, Colorado
    I would not code an E/M for this scenario. The doctor must document the history portion of the HPI, so the HPI is null and void in this case. He cannot simply sign off on the nurses notes. From what you state in the post he didn't document any part of an E/M and did nothing but suture. Did he even document the procedure and length?
    Lisa Bledsoe, CPC, CPMA

  3. #3
    St.Petersburg, Fl
    the good old saying stands if it wasn't documented it didn't happen. If the dr. refuses to document the suture or he even seen the patient the only thing you can code is a nurses visit as a 99211 level of service. The best way to get him to do his documentation is to inform him as gently as you can that he will not get paid for the sutures or the visit because it lacks documentation and it would be fraud if you coded or billed it any other way.
    Alecia Peck CPC

  4. Default
    I agree with Lisa and CMAC, no MD documentation, no E/M bill. Depending on the documentation (by the MD, not nursing), I might would try to bill for the suturing, but from the sounds of it, he didn't bother doing that so it appears that he was not even around.

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