# What to charge if anything?



## bwerner (Sep 12, 2008)

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.


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## KDoerfler (Sep 12, 2008)

If it wasn't documented, it didn't happen!  Hope this helps!  Kate


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## LOVE2CODE (Sep 12, 2008)

KDoerfler said:


> If it wasn't documented, it didn't happen!  Hope this helps!  Kate



  I agree.....


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## bwerner (Sep 12, 2008)

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?


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## Belinda Frisch (Sep 12, 2008)

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. 



bwerner said:


> 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
> ...


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## bwerner (Sep 12, 2008)

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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