Wiki New Patient visit vs H&P

[maine4me]

I am having a problem with our general surgeons when they see a new patient and make the decision to perform surgery. The note that is entered into the patient's paper chart, is brief at best. However, the actual detailed note from this visit is entered into the hospital EMR as the H&P. I have a request from Medicare for the office visit, can I send the H&P note from the hospital EMR? If I use the note from the patient's office chart the visit is unbillable.

As anyone come across this issue?

 

[FTessaBartels]

Date of Service

First ... an H&P is a hospital requirement and has nothing to do with physician billing. Although the H&P documentaiton is frequently used to code the Initial Hospital Visit.

I think what is happening in your practice is that the surgeons do not want to have to document twice ... once for the office visit and again to satisfy the hospital's requirement for an H&P. So they are documenting their office visit as a hospital H&P.

That is perfectly fine.

HOWEVER ... the H&P should have as a date of service the same date as the office visit. The date of admission will be different.
For example:
Date of service: 07-03-12
Date of Admission: 07-05-12

Two processes should help you ....
FIRST - the physician should document in the "paper chart" something like:
"Decision for surgery; visit documented as hospital H&P for admission on mm/dd/yy."

SECOND - you print out a copy of the hospital H&P from the hospital EMR.

If any payer requests documentation of the office visit, you provide BOTH documents.

Hope that helps.

F Tessa Bartels, CPC, CEMC