Wiki ER visit without any MDM

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AuditU

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Hi!
I have a question regarding level of service for E/M visit - Provider performed HPI and exam. Proceeded to order tests, etc., but patient left AMA. Would this be billed? My thinking is no, because there was technically not any medical decision making that took place.

Thanks,
J
 
oops anyway provider did work including Hand P as well as ordering tests. The patient in the ED is almost always new to provider which captures another MDM element. But I'd agree you don't have a complete plan of care or treatment. I have seen cases like this billed based on the documentation given, other times not billed. But my leaning would be that there is enough documentation to support billing. My only caveat would be if the patient waited for hours in the ED and left in frustration and that is documented. Jim
 
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