Wiki H & P

[Rochelle Fillyaw]

I have a question in regards H & P documentation.
Example:
We schedule a patient to be admitted to the hospital to have a sotalol infusion done. Can the provider use the last office visit as the H & P and document on it "no changes" sign and date and bill a 99221? Does a new document need to be created? (admit would not be on the same day as the office visit). Would the following be enough for a 99221
Date:
HPI: Reviewed from visit of __________. HPI essentially unchanged except for
ROS and Comp. History—Reviewed from stated visit, history essentially unchanged except for
Physical exam- Vitals from intake reviewed. Exam from stated visit essentially unchanged except for
Impression: AFib.
Plan: Tikosyn/ Sotolol Induction
Total time spent on today’s admission ___________. More than 50% of the time was spent on coordination of care, including orders,
reviewing labs/ diagnostics and counseling patient on risks and possible adverse events of the medication.
See previous office note
Phys Name/sig. /date

Thank you in advance for all your help.

 

[thomas7331]

My first question would be is this patient really being admitted? Infusions are usually a hospital outpatient service that does not require admission. 99221 would only be used for an admission to inpatient status at a hospital when the patient is expected to be remaining in the hospital for treatment for more than two nights.

In any case, the code assignment for a hospital E&M service (admission or otherwise) must reflect the in-person services performed on that date. They may review the previous notes as part of that service (so per guidelines you could give credit for the ROS and PFSH as documented above since those can be pulled from the prior records), but you would not count the HPI or exam toward your E&M on that date. You would assign your code based on the services that were actually documented as having been performed in person as part of the admission.

 

[Rochelle Fillyaw]

Thank you for your assistance!!

 

[twizzle]

My first question would be is this patient really being admitted? Infusions are usually a hospital outpatient service that does not require admission. 99221 would only be used for an admission to inpatient status at a hospital when the patient is expected to be remaining in the hospital for treatment for more than two nights.

In any case, the code assignment for a hospital E&M service (admission or otherwise) must reflect the in-person services performed on that date. They may review the previous notes as part of that service (so per guidelines you could give credit for the ROS and PFSH as documented above since those can be pulled from the prior records), but you would not count the HPI or exam toward your E&M on that date. You would assign your code based on the services that were actually documented as having been performed in person as part of the admission.

I agree with Thomas although it is not uncommon to admit patients to IP who are being initiated with Tikosyn therapy. Regular monitoring with EKGs is required because these drugs qualify as intensive monitoring for toxicity.