Initial hospital charge

[bbeatty]

If a doctor sees a patient in the office but then direct admits them to the hospital, can he use the H&P dictated at the time of the visit for the initial inpatient H&P? He clearly stated that he was sending the patient to the hospital as a direct admit. Any thoughts?

 

[FTessaBartels]

Depends but probably

Everything depends on documentation, but I think what you are asking is whether you can use the "H&P" dictated by the physician as a result of the office visit as documentation for the initial hospital visit.

Scenario 1: Patient presents to office and physician directs patient to hospital for admission. Physician (or his colleague in same specialty, same practice), sees patient same DOS in the hospital for initial visit. YES you will use all documentation for this DOS as part of the Initial Hospital Visit. You will NOT code the office visit separately.

Scenario 2: Patient present to office and physician directs patient to hospital for admission. Physician dictates a "hospital H&P" which is faxed (or electronically submitted) to hospital, but physician does NOT see patient at the hospital until next day. Code the office visit for first DOS, based on the documentation available (i.e. the "H&P"). Code Initial Hospital Visit based on documentation of visit on NEXT day ... YES, MD can reference the history from his previously dictated H&P, but MUST perform and document a NEW Exam and New MDM.

Hope that helps.

F Tessa Bartels, CPC, CEMC