if is not documentated, it was not done. I was instructed my a recent auditor hired to do a external audit, that if you do not have all the elements required then you do not get to bill it. I have always been told modifier 52 is for procedures, modifier 52 is not an E/M modifier.
Did the doctor see the patient in the office and then see the patient in the hospital (same day)? If so, you can combine the two visits and sometimes get a higher level code.
"When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (eg, hospital emergency department, observation status in a hospital, physician's office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting."-CPT book
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