Wiki inpatient admission

[veeramani14]

Hello all, can anyone clarify this.

For inpatient admissions we have a house physician overnight service. When a patient is admitted the house physician completes and documents the full history and physical. When I see the patient the next day I do a complete history and physicaI and then cosign the house physician's history and physical. I then write a progress note and code a 99221-99223 for the day I see the patient.

Am I documenting the encounter and coding it correctly?

If not:

Do I need to write an addendum to the house physician's history and physical and if so what is needed in the documentation?

Or do I need to write a new complete history and physical?


Thank you,
Veera

 

[mitchellde]

it depends, if the house physician bills an initial inpatient encounter then you can only bill for subsequent encounters. If the house physician did not bill a visit then you will need to document the entire H&P in order to bill it, you cannot make another physician's work your own.

 

[veeramani14]

Thank you