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Documentation

  1. #1
    Default Documentation
    Medical Coding Books
    Patient goes to hospital for evaluation/observation and phone orders are called in, however MD may never see patient. The hospital nursing staff will write phone orders in the chart and the physician will sign off on them. Does this qualify for a bill???? I have no notes that the MD saw the patient only phone orders. I have not been billing, based on what I've been told. No documentation it didn't happen. Does phone order qualify for a bill???
    Please help with this...
    Thanks

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    I don' think so. In order to report an observation code you have to meet all 3 key components, which would obviously require an exam by the doctor.

  3. #3
    Default response to documentation
    no physician exam in the hospital...oh my!!
    yes, this case can not be billed

    Quote Originally Posted by jsturgeon View Post
    Patient goes to hospital for evaluation/observation and phone orders are called in, however MD may never see patient. The hospital nursing staff will write phone orders in the chart and the physician will sign off on them. Does this qualify for a bill???? I have no notes that the MD saw the patient only phone orders. I have not been billing, based on what I've been told. No documentation it didn't happen. Does phone order qualify for a bill???
    Please help with this...
    Thanks
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

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