If I read your scenario correctly, this was an inpatient consult.
Our Compliance office has indicated that if we can determine the date of service with reasonable accuracy based on the rest of the inpatient record, then we can bill the service.
Things we look at ... notes from nursing "CVT here this morning"
Notes from the requesting physician "Ask CVT to consult"
Our hospital order system has a time/date stamp for completion of the order. Consults are listed as an order and have to be "completed" ... so that gives us a date as well.
I would ask that the provider amend the original note to include a date of service, if they can reasonably determine the DOS.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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