Wiki Not meeting admit levels for inpt

[raidaste]

I have a physician that admitted a patient to the hospital after seeing them in the clinic. They filled out out H & P form but it in no way meets the documentation requirement for the 99221 detail or comp. If he was not the admitting then I could charge a subsequent but is it the same for this situation. Since he's the admitting physician is there an e/m I can charge for the admit day.
I thought of using the office note too but it doesn't give me added info. What, if any, can be charged for this admit day?

 

[mitchellde]

some payers will instruct you to use the subsequent level, this is what medicare states, and others will say to use the unlisted E&M code. Was the provider informed that minimal documentation had not been obtained?

 

[raidaste]

Yes, he's been told before the requirements previously. He's done usually well since I've taken over and so I don't ever run into this problem but this one confused me.
Also this particular patient was a post surgical patient w/in the global period and had developed cellulitis and was admitted for IV antibiotics. So now I'm wondering if I can bill anything at all for this stay since it was a postop infection.