Wiki Decision for Surgery

[sctaylor]

Please help! I have no idea what to do with this. Can I even bill with this?

Thank you!

This is the entire note dictated by the surgeon:

CT scan shows a fluid collection in her anterior abdominal wall. It is smaller than the abscess that was drained back in July. I plan operative I and D tomorrow and will leave area open for packing. My resident will discuss this with her and I will see her in am.

 

[Naveen Rachagolla]

In this case the physician can bill the Em with mod 57, and to know more about the the physician and the resident billing guidelines go through the below link.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

 

[dclark7]

There is nothing billable in this note, there is no documentation that he saw or examined the patient. It looks like all he did was review the CT and decide to do surgery. IF he had dicated any sort of Hx and exam you could have billed with a 57 modifier. If the resident examined the patient the surgeon would still have had to be physically present during the key portions of the service in order to bill under teaching physician rules.

 

[sctaylor]

Thank you for the advice. I didn't think I could bill for it either. I only billed for the procedure performed in the OR.