# Blank physician t-sheet



## QuadRider (Jun 30, 2010)

Can a hospital facility coder charge for any E/M level if the physician t-sheet only has a dx & signature on it?  There is no HPI, ROS, Physicial Exam or anything done.  Only a dx.  And he did write an RX.  Not noted on the t-sheet.


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## JulesofColorado (Jul 1, 2010)

Do you have a dictation? If not, I would request the provider to complete the T-sheet and dictate a report before coding.


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## QuadRider (Jul 1, 2010)

No dictation sheet.  Will request completion of t-sheet.  I realize that being a physician coder, I can't charge until documentation on physician t-sheet is complete, (no exam done unless documented).  I used to be a facility coder, needing a reminder of facility charging though for the hospital I work with.  Thank you for your input always


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## jimbo1231 (Jul 4, 2010)

*You can code on the facility side but....*

You don't need physician documentation for a facility level. So if this is a patient who was triaged and left or a similar scenario, the blank T-Sheet makes sense. But if the patient was treated by the physician, the T should ibe returned for documentation for medical legal reasons as well as coding the physician services.

Jim


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