inpatient e/m

[maudys]

per federal regulations, if a patient is admitted within 30 days of their last admission, for similar diagnosis, the initial H&P may be used with an admit note written updating the patient's course of illness and new examination findings since that time.

my question is, can i use the initial H&P combined with the new info to assign the initial inpatient e/m level for the new admission?

[FTessaBartels]

Yes, you can use the history from the first H&P (properly noted in your current documentation as to source). Your exam and MDM need to stand alone.

F Tessa Bartels, CPC, CEMC