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I don't think this would be billable as there is no medical decision making, no assessment, and no plan. Even if you determined it could be billed on time, in a situation like this, I would not bill.
 
I don't think this would be billable as there is no medical decision making, no assessment, and no plan. Even if you determined it could be billed on time, in a situation like this, I would not bill.
the provider documented that the patient should see a psychiatrist and patient left because the provider wouldn’t prescribe pain medication
 
the provider documented that the patient should see a psychiatrist and patient left because the provider wouldn’t prescribe pain medication
I don't care for assumptions, but this was perhaps a drug seeking patient who left once the provider would not prescribe. However, if the physician were unable to even complete the exam and take history to make a thorough assessment, I would just cut my losses and not bill.
 
I would think this would all be based upon the notes. He had to come up with the fact the patient needs to see a psychiatrist from somewhere- history, exam, cc.... I would use an audit tool and see if I could get a level of service.
 
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