# Albuterol - I have an account that I'm



## mslori7 (Feb 25, 2010)

Hi,

I have an account that I'm auditing for an inpatient stay.  The patient has been prescribed Albuterol by the physician in which the nurse takes to the patient room and leave by the bedside.  We are having a debate because the nurse auditors are going by their nurse protocols and I'm going by documentation.  The problem is that when the albuterol is left by the patients bedside, the nurse does not document the patients use of the albuterol so they leave the charge on the bill.  My point is that, it does not matter if pharmacy tells you to leave it on the bill even if the patient does not use the albuterol.  This is a compliance issue about documentation, can someone give me there take on this?

Lori


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## melloyello31 (Mar 8, 2010)

The "golden rule" we as coders have to live by is "Not Documented, not done". How can you bill somebody if there is no documentation or proof that the patient actually took it? Are they breaking the law by actually charging pt's for meds if they actually don't see the pt taking it? Hope my little tit-bit helps.


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