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Wiki E/M initial

Coding2

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Watton, MI
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Hello,

I am new to E/M levels. This question is facility based.

I am wondering when a physician admits a patient to either inpatient/observation how do you know if he will take an ER charge 99281 to 99285 or critical or takes the appropriate admission E/M (inpatient/observation/same day). The way I am being shown is if the ER physician admits the patient and the attending does not dictate an H&P also during the admission the ER doc will take the IP/observation E/M and if the attending does dictate an H&P then the ER doc takes the ER E/M.

Also if the ER physician is the attending physician and patient is admitted through the ER, does he/she send an ER e/m through and then take the H&P also, or would it just be the H&P level submitted by the attending and the hospital has no e/m on the claim? Does this physician dictate an ER H&P and a regular H&P?

I work in a smaller hospital where our ER docs are also the attending on the floor.

Thank you. Any information you can direct me to on this is greatly appreciated.
 
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