Wiki ER visit with missing components ??

[VRMoran]

Would you code this ER visit as a level I even though appears to be missing components? This is all that was documented in the chart. Thank you

Fetal Medicine - ER visit

Called by ER - vag bleeding, Radiology sono - 6w IUP no FHR.

IMPRESSION: Missed ab. There is a >50% likelihood of aneuploidy given first trimester growth lag.

DISPOSITION: Discussed with pt and sister. Suggest D&C and Natera (microarray) genetic testing. Escorting pt to AWHS for F/U visit.
Needs Type and Rh.

 

[jimbo1231]

No

I'd return the chart for completion if the phsysician did more than is documented. Otherwise this isn't a billable service.

Jim