Can the physician count notes documented by the triage nurse toward the level of service billed?
The physician’s services are supported by his or her documentation alone. Documentation by hospital staff cannot count towards the level of physician’s service billed–be it in the ER or for other visits such as subsequent hospital visits. For example, if a hospital triage nurse documented most of the patient’s exam then the physician would only report that level of service equal to the exam he or she performed. Please note ER visits using CPT codes 99281-99285 require the three key components (history, exam and decision-making); and the lower the levels of these components yields a lower level of service to be billed.
Related Questions
- When is the cost for a health benefit service provided by a professional (e.g. physician, therapist, nurse practitioner, etc.), incurred for purposes of ERRP?
- Documentation for ER visits: Can the physician count notes documented by the triage nurse toward the level of service billed?
- Can the physician count notes documented by the triage nurse toward the level of service billed?
