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Can this be charged???

  1. #1
    Cool Can this be charged???
    Medical Coding Books
    Here is a situation where a patient calls the office with multiple complaints. He was scheduled to have an A-V fistula created next week. Had lab work done today showing a CR of 5.4. The call is taken by CRNP. She talks to physician, who wants pt admitted to hospital to have placement of temporary hemodialysis catheter then start dialysis.

    Here is the situation, the CRNP dictated a H&P solely on phone conversation & contents of chart. The physician sees pt in hospital, & dictates an addendum to H&P, stating that he examined the pt. "I performed key elements of physical exam, reviewed medications & lab data. I discussed with patient regarding the need for the placement of a temp. catheter for which he agreed. I consulted Vascular Surgeon. Hemodialysis will be performed as per protocol. ESA support will be continued during dialysis."

    I know I can't bill this under the CRNP since she did not see pt. face to face. Is there anyway I can bill this under the physician. I'm thinking NO!!

  2. #2
    Milwaukee WI
    Default Is this ALL he dictated?
    If the statement you quote is ALL he dictated, then I don't think you have enough.

    If he has his own chief complaint and HPI, references the ROS & PFSH from NP note, and documents actual exam, then you might have enough for initial hospital visit. Do you have full access to the entire patient chart? You might want to request it to see if there is additional documentation.

    Good Luck!

    F Tessa Bartels, CPC, CPC-E/M

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