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No date of service

  1. #1
    Default No date of service
    Medical Coding Books
    I'm really not happy asking this question but I want to be sure I am right before I go back to the providers.

    I have a consult note in front of, beautiful note. No date of service anywhere. There isn't even a dictation date and he didn't date it when he signed it. This is at least 6 months old. I am thinking I can't bill for this at all.

    The patient was in the hospital for over a week and I can tell they asked for CVT to come in on 2/9/09, but I have no idea when they actually did the consult. The PA did the service and they don't keep track of who they see in the hospital. Which is why we missed billing it back in Feb more than likely.

    Thanks in advance.

    Laura, CPC, CEMC

  2. #2
    Milwaukee WI
    Default INpatient record
    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
    Last edited by FTessaBartels; 08-19-2009 at 11:14 AM.

  3. #3
    Thanks Tessa, I'll check into that. Hopefully nursing notes will save the day!

    Unfortunately the requests are handwritten, I don't think they log them in the computer but fingers crossed maybe I'll get lucky.


    Laura, CPC, CEMC

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