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Question: The following chart note was billed as 99232
55 y.o. female of lupus, HTN, raynaud, GERD, and CML on Gleevec who came into ED on 11/30 night with wheezing, cough, and difficulty breathing requiring intubation in the ED. Being treated for ARDS, bilateral pna, septic shock. Off pressors at this point with decent MAP, lactate is clearing, but poor UOP with increase in SCr from 0.68 to 1.73. Urine studies c/w pre-renal etiology (0.2), but may also be early ATN in the setting of shock (more likely). Was given 1 PRBC today for anemia and resuscitation, but no response in UOP. Lasix has been held
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Plan:
- Bladder scan to ensure functional foley
- Renal US
- Nephrology consult in am (currently no acidosis or electrolyte abnormalities that would necessitate urgent dialysis)
- Avoid overresuscitation
- Repeat CBC to ensure appropriate response
Is it okay to bill an E/M service when there is no indication face-to-face contact by the provider?
55 y.o. female of lupus, HTN, raynaud, GERD, and CML on Gleevec who came into ED on 11/30 night with wheezing, cough, and difficulty breathing requiring intubation in the ED. Being treated for ARDS, bilateral pna, septic shock. Off pressors at this point with decent MAP, lactate is clearing, but poor UOP with increase in SCr from 0.68 to 1.73. Urine studies c/w pre-renal etiology (0.2), but may also be early ATN in the setting of shock (more likely). Was given 1 PRBC today for anemia and resuscitation, but no response in UOP. Lasix has been held
*
Plan:
- Bladder scan to ensure functional foley
- Renal US
- Nephrology consult in am (currently no acidosis or electrolyte abnormalities that would necessitate urgent dialysis)
- Avoid overresuscitation
- Repeat CBC to ensure appropriate response
Is it okay to bill an E/M service when there is no indication face-to-face contact by the provider?