msnbabs001
Contributor
I am auditing some inpatient hospital notes and I am trying to determine if I can use the electronic H&P by the resident along with the Handwritten H&P of the resident and the Attending's handwritten H&P.
If you used the following information would you bill based on the handwritten notes only or would you use both the hand written and the electonic H&P to determine the E/M level?
Example –
Resident handwritten H&P 7/4/17 2pm
Attending handwritten H&P 7/4/17 3pm w/attestation that he saw and examined patient, agree with resident’s documentation and plan of care.
Electronic H&P by resident(has more information than handwritten) dictated 7/4/17 2:30pm
electronically signed by resident 7/4/17 2:45
electronically signed by Attending 7/6/17 8am (no attestation)
I would think the handwritten only since there is no proof that the Attending looked at the electronic H&P.
Thank you for any help you can give me.
If you used the following information would you bill based on the handwritten notes only or would you use both the hand written and the electonic H&P to determine the E/M level?
Example –
Resident handwritten H&P 7/4/17 2pm
Attending handwritten H&P 7/4/17 3pm w/attestation that he saw and examined patient, agree with resident’s documentation and plan of care.
Electronic H&P by resident(has more information than handwritten) dictated 7/4/17 2:30pm
electronically signed by resident 7/4/17 2:45
electronically signed by Attending 7/6/17 8am (no attestation)
I would think the handwritten only since there is no proof that the Attending looked at the electronic H&P.
Thank you for any help you can give me.
