A patient presents to the Emergency Room

A patient presents to the Emergency Room with severe shortness of breath, extreme lethargy, and intermittent loss of consciousness. The patient is unaccompanied and unable to provide past history of diagnoses or treatments. According to the EHR, the patient had been admitted to the facility for a 48-hour observation 3 months ago. Upon review of the patient’s medical record, the History and Physical and Discharge Summary were not available in the medical chart. The Emergency Room provider attempted to contact the patient’s attending physician and learned the provider was out of the country on vacation. What is the impact to billing and reimbursement due to the incomplete clinical documentation?

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