AHA Coding Clinic® for HCPCS - 2013 Issue 1; ASK the EDITOR

Reporting of procedure without physician documentation

A hospital-employed nurse or technician may perform a procedure in an emergency department or clinic that was ordered by a physician, examples of these services include, but are not limited to, drug infusions, foley catheter insertions, strapping and splint applications. Can the hospital code for the procedure without the note from the physician describing the procedure?  ...

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