Wiki ER Consult billing question

[treece@gcsco.net]

My Dr (orthopedic surgeon) did a consult on a patient in the ER, pt had injury to shoulder, hand, and hip. Per the consult note:
" patient fell out of bed and had right hip pain, right shoulder pain and right hand pain. Workup revealed evidence of a right intertrochanteric hip fracture, a right shoulder dislocation, and a right 5th metacarpal fracture. closed reduction was successfully performed by the emergency room physician of the right shoulder, and splint applied to the right 5th metacarpal. orthopedics was consulted for evaluation and management of the right hip fracture"

Dr says to bill for closed reduction without anesthesia for the shoulder and the hand. However, there is no op note for these, and the consult clearly says the ER doc did the reduction on the shoulder. He did do an ORIF on the hip the next day.
What is the best way to code this, I feel like we should just bill the consult and the ORIF of the hip. Then when the patient comes for post op of the other two conditions, we would just bill for an office visit.

Any information will be greatly appreciated. Thanks in advance!!

 

[FTessaBartels]

No documentation of service

If there is no documentation of the service, you cannot code it. In this case you even have documentation that someone ELSE performed the service.

Physicians need to document what they did. Coders will code what is documented.

Hope that helps.

F Tessa Bartels, CPC, CEMC