Wiki need help with observation H&P

[trarut]

I am desperate for help! I've only coded office E/M's but I've been handed a stack of hospital cards and told to code them. I've been combing the internet for a few days and can't find the answers I need.

The hospital visits are for patients the doctor admitted (for lack of a better term right now) to observation for intraperitoneal chemo with an overnight stay to watch for reaction. He sent a copy of his latest office note to the hospital with the order for admission indicating "H&P attached". The office note is dated no more than 5 days prior the patient going to the hospital.

1. Can I use the office note for H&P for the observation service if the doctor doesn't refer to it in his documentation for the visit in hospital?

2. If I have a handwritten progress note and a discharge summary from the doctor that were done on the same day, can I use both notes to determine the level of service?

Thanks!
Tracy

 

[purplescarf23]

I work these type of scenarios everyday. Below is my opinion.

1. Can I use the office note for H&P for the observation service if the doctor doesn't refer to it in his documentation for the visit in hospital?
The provider can 'refer' to a previous note with date and who's note in the past they are referring to but not use it as the current H&P. There should be a new note dictated. The previous H&P 5 days ago would have been billed out for that date of service.

2. If I have a handwritten progress note and a discharge summary from the doctor that were done on the same day, can I use both notes to determine the level of service?
Yes you certainly can. Combine all the elements to determine your level. However if they are the discharging physician you will end up with 99217(OBS) or 99238-less than 30 minutes/99239-greater than 30 minutes(Inpt), where elements do not matter.

Kelsey, CPC, CEMC

 

[trarut]

Oh my gosh! I just came back to this thread and found your response, Kelsey; I appreciate it.

I ended up reaching out to a consultant that we've used in the past and have been doing the best I can with the (limited) info he provided. Does anyone have a recommendation for educational sources for this type of coding?