Progress Note vs Physician Order

This is in an inpatient setting......

I have a physician who saw a patient during their admission and is charging a subsequent visit for a specific date during this admission. The physician did not document any notes in the "progress note section" but does have some orders in the "order section", therefore he apparently saw the patient on this specific date but did not document in the progress notes. The question is......If the physician states that he saw a patient for a subsequent visit but did not document in the progress notes and did document orders, can he bill for the subsequent on the date in question since their were orders (they were not verbal either)? Can we use the orders as proof of face-to-face if they do not say verbal?

re: Progress Note vs Physician Order

you are out of luck. Even a subsequent visit needs some documentation of a visit - need 2 of 3 even for level 1 visit or note of time spent

re: Progress Note vs Physician Order

No E/M. You don't have any elements to support an E/M. Unless it is documented somewhere in the patient's chart then you cannot bill for it. Remember the rule of thumb, "if it isn't documented, then it never happened". If the record were suponead to court, the only thing that count's is what is in writing.