Wiki E & M and no dictation

[carol52]

One of our Doc's sees an existing pt in the office and does not dictate anything but orders in the chart. Pt is not in a global. This is ongoing wound care. Has been a month since that pt was seen. He thinks he can bill a 99213 for this. Can someone help me explain this to him? Thanks for everyone's help

 

[mitchellde]

you cannot code and bill for what is not documented. I am not sure how much more clear you can make this point. not documented = not codeable, not coded= no claim, no claim = no reimbursement.
If you as the coder know there is no documentation to support the chosen codes, then you cannot, must not bill it.

 

[Cynthia Hughes]

An E/M service to an established patient must be supported by 2 of 3 key components or time spent counseling and coordinating care. Assuming the orders support some level of medical decision making, you still must have documentation of history or exam supporting the E/M code selection. Ask the physician to show you the documentation elements (eg, chief complaint, history of present illness, exam elements) that support the 99213 level of service and are not pre- or post-service work of any procedure during the encounter. Using an E/M review checklist to guide the conversation may be helpful.