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Initial Hospital Care without a Detailed hx and exam

C

CatchTheWind

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648
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Boca Raton, FL
The lowest level code for initial inpatient visit requires a detailed history and detailed exam. So how do you code the visit if the history and exam were only problem-focused or expanded problem focused?
 
espressoguy said:
Even though this is an initial visit, it is acceptable to code this as a subsequent visit if only a PF or EPF history and/or exam is documented.
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It is only acceptable if the physician is not the admitting physician. If it is the admitting physician then he would need to be queried about the PE and HPI.
 
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