Wiki ? about billing HP versus office visit

[coder25]

Hello,

I was wondering if a patient was seen two days ago and was directly admitted at that time for DVT; however, however the admitting HP was done by a resident and there is no attestation in the EHMR, is it accepatable to bill out the office visit for the same day, knowing that the HP will be unbillable???

This always confuses me when they do not have an attestation on their HPs, but they saw the patient in the office on the same day when admission was recommended.

Thanks for the help!

Peggy

 

[FTessaBartels]

Bill Initial Hospital Visit

You will bill the initial hospital visit based on the documentation you DO have. If you need it, you can use the resident's documented PFSH and ROS if your physician has countersigned the resident's paperwork (EVEN without attestation statement).

CPT clearly tells us that if the patient is admitted to the hospital in the course of an encounter in another place of service, to code only the hospital admit. Don't let the source of the paperwork throw you. BUT I would make sure a copy of the office note is put in the patient's hospital record in case of future audit.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[coder25]

Tessa,

Thanks for that info, however, there is no signature on the resident's note, therefore does this make both the office visit and hospital admission not billable??

Peggy

 

[FTessaBartels]

Bill based on physician documentation

Just bill based on the physician's own documentation. If you don't have a sufficiently detailed history or exam you'll need to use 99499 Unlisted E/M.

NOTE ... if the patient has commercial insurance, get the physician to sign that resident note and it can be used. Most commercial payers do not required the at-the-bedside face-to-face supervision that the government payers require.

F Tessa Bartels, CPC, CEMC