We have a patient who came to the ER and was in need for a blood transfusion which was approved by the PCP, so to be in compliance with our facility policy we admitted them to observation. Once the patient was discharged the ordering doctor claimed that he never ordered the patient to be admitted to observation and is now refusing to complete an H&P. Despite our hard efforts, we cannot convince him that he needs to complete the H&P and we will not recieve one.

Here's my problem: We still need to bill for this patient since we have provided the services. Can we bill 99218 (Observation straightforward complexity) if we don't have an H&P? Can we code from the ER H&P? I'm thinking that this isn't legal, but if so, does anyone know where I can find documentation to back this up?


Here's another situation:

A patient came to the ER and was admitted to Observation. However, the patient's health rapidly became worse after she was placed in an observation bed and had to be trasferred to another facility before the doctor ever saw the patient. Obviously we can't expect the Dr to complete an H &P because she never evaluated the patient, but again, can we bill the observation or do we need to bill it as an extended ER stay? And if we do bill it as observation, is it legal to use the ER H&P? I'm just trying to cover myself and prevent us from getting in trouble in the event of an audit. This battle will be a whole lot easier to fight with documentation to back me up. Keep in mind we are billing facility, not physician.

Thanks for your help!