It's just a piece of paper
Debra is absolutely correct. The visit may or may not be billable (might be covered under global surgery package).
That being said, I'd like to address your specific question - can you use the dictated H&P as documentation for the office visit?
Our practice is hospital based - i.e. we see all patients in a hospital outpatient clinic.
I have one provider who likes to use the hospital's H&P form for all new patients - it's four pages long and has all the spaces / prompts for the physician to ensure a complete report (as needed, of course). It doesn't make any difference that the piece of paper used is titled "Admission History and Physical" - it is still the record of the "office" visit for that patient.
I have also seen cases where a new patient comes for a consultation with the surgeon, who makes the decision for surgery at that initial office visit. If the patient can be scheduled within the next few days, the surgeon will usually dictate the hospital H&P right away (saves two dictations), but the date of service is still the office visit, and the documentation supports the appropriate level of new patient office visit.
So, yes, it is possible that what your surgeon is documenting is perfectly fine. But read Debra's comments again ... if the decision for surgery was made at a previous visit and the only reason for THIS visit is to get the H&P done before the patient shows up on the day of surgery, this is NOT a billable service. The reimbursement for the surgery itself includes payment for the necessary pre-op H&P.
Hope that doesn't further confuse you.
F Tessa Bartels, CPC, CEMC