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Need help with ER level

  1. Default Need help with ER level
    Medical Coding Books
    This is the PA's dictation: 33 yr male was going to light a wood pile using gas. had tried earlier and wouldn't go. Must have been an ember that ignited w/gas & flashed back on him. Face has 2nd degree burns on nose, forehead, 1st degree on cheeks, 1st to 2nd on lips. Has blistering L upper arm on axilla side, L thumb 2nd degree. Also 2nd burn down L axilla side to pants line. Dr. Blank was called in to see pat. 2 IV's started w/ #18 gauge needles running wide open initially. Morphine sulfate 5mg given every 10 min up to 15 mg so far. BP running 163/99, was higher initially. HR in 90's. O2 sat 99% on room air. Heart reg. Lungs CTA bilateral. Dr. Blank estimates 10-15% BSA burned. Hair on chest also singed but chest no blistered. After talking with pat in burn unit all burns covered w/saline gauzwe. He was cooled down w/wet towels initially. PMH: seasonal allergies. Surgeries: none, MEds. Fexo & Flut. Allergies:NKA.
    IMP: 1st & 2nd & possibly 3rd degree burnes to 10-15% BSA.
    Plan: Transfer to burn unit in another city by Life Flight

    First the PA saw the patient than the Dr saw the patient. The dictation was done by the PA. The MDM is high but not much HPI elements or ROS. How would you bill this? Thanks.

  2. #2
    Columbia, MO
    Are billing for the PA or the Facility. The physician must dictate his own note before this could be a physician visit. Per CR1776, shared services:
    If there is no face to face encounter documented between the physician and the patient( even if the physicians signs off on the documentation provided by the NPP) then the visit must be billed under the NPP.
    As far as visit level then are you billing the PA level or the facility level?

    Debra A. Mitchell, MSPH, CPC-H

  3. Default Help with E/R visit
    I was billing for the physician. Thanks.

  4. #4
    Columbia, MO
    For a provider level then I get a level 3.

    Debra A. Mitchell, MSPH, CPC-H

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