Wiki Does a code exist??

[magmae]

Can any advise if a code exists? Patient is inpatient at hospital.....Doc reviewed pt chart ect on floor prior to seeing pt. Doc spoke to pt but she would not let him do exam and made him leave room.... Is there a code to bill since there was no actual exam performed??

Or - does the fact that he spoke to her count as 'face-face contact' per cpt descriptors

 

[MnTwins29]

Initial or subsequent visit? If the latter, there is much less documentation required. Like with office visits, any statement about the general appearance of the patient? Also, anything else other than just "patient refused"?

Or...if time is documented, unit/floor time is allowed to be used for calculating the time spent on coordination of care as well as the bedside time. The E/M guidelines in CPT state this, including "...the time to establish and/or review the patient's chart..."