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Observation Question

  1. #1
    Default Observation Question
    Medical Coding Books
    Can someone please help me. The pt came to the hospital to get a spinal tap done by the radiologist but my doctor who is a neurologist wrote orders and a discharge summary but never saw the patient. Pt was admitted and discharge on same day. Can my doctor charge a 99234 for the documentation she prepared for that patient even if she didn't see the patient? Any help is appreciated!!!

  2. #2
    North Carolina
    99234 requires 3 components; Detailed HX, detailed exam and MDM of low complexity. No face-to-face rules out the ability to charge for this.

  3. #3
    So if I can't use that code is there a code I can use because she did write orders and did a discharge summary.

  4. #4
    North Carolina
    The paperwork involved for patient discharge is paid through the pre- and/or post-service work of an E/M service. Discharge services performed by staff (i.e. a RN) do not count toward the physicians discharge time. Medicare is very clear on the face-to-face requirements and most carriers follow the same standards. Since no face-to-face took place, I don't see a billable charge. In my opinion, the work involved with the discharge was a free service.

  5. #5
    Thanks for your advice. I didn't think there was but then again I wasn't for sure. Thanks again

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