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What to charge if anything?

  1. #1
    Unhappy What to charge if anything?
    Exam Training Packages
    We have a new obgyn who hates to dictate. One of her patients came into the hospital in observation status and this is all we got from doctor.

    08/26/08
    reg diet
    FHT Q4
    ambulate to BR (bathroon?) PRN
    vitals per routine
    Toco continuous (toco machine reads contractions)
    call for stat reading of US in am
    Ambien 10mg prn, CBC, DIC panel am

    08/27/08
    Discharge home, F/U 09/11/08

    Doesn't give much as you can see. Need opinions.

  2. #2
    Default
    If it wasn't documented, it didn't happen! Hope this helps! Kate

  3. #3
    Smile
    Quote Originally Posted by KDoerfler View Post
    If it wasn't documented, it didn't happen! Hope this helps! Kate
    I agree.....

  4. #4
    Question
    Since the patient is her ob patient normally does that matter at all. She documented a little as you can see, can we even charge a 99212 for the visit? Obviously, not a 99218 & 99217, but anything?

    I understand the not documented not done saying, but are you saying I can't charge for anything?

  5. #5
    Default
    There is no HPI here, which automatically excludes the provider from billing an observation admission; even the lowest code requires a detailed or comprehensive minimum. I would say even a 99212 would be a stretch because there's really not a chief complaint/HPI here. The MDM would be more than sufficient, but there's not even constitutional for exam because there's no proof of THREE vitals. You could bill an unlisted E/M 99499 with a copy of the note and maybe get some payment, but the effort probably isn't worth the return or the risk of turning insurance company attention onto a non-documenter.

    Quote Originally Posted by bwerner View Post
    We have a new obgyn who hates to dictate. One of her patients came into the hospital in observation status and this is all we got from doctor.

    08/26/08
    reg diet
    FHT Q4
    ambulate to BR (bathroon?) PRN
    vitals per routine
    Toco continuous (toco machine reads contractions)
    call for stat reading of US in am
    Ambien 10mg prn, CBC, DIC panel am

    08/27/08
    Discharge home, F/U 09/11/08

    Doesn't give much as you can see. Need opinions.

  6. #6
    Default
    Belinda Frisch-

    Thank you very much. I noticed writting this up for opinions that I didn't have a clue to why this patient was even in the hospital. I am going to copy this for her and maybe she can get in better habits of documenting. I totally agree with what you said. The MDM is the only good point in the documentation because of the lab work and Rx.

    Thanks again!

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