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office visit then admit


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i know this has been asked many times, but i've been asked by a co-worker and want to make sure we're getting it right here..

pt seen in the office, provider decides to admit. when coder asked the doc about a missing admit note in the hospital he stated that he saw that patient in the clinic so that was the admit note. because this is just a clinic note (with the decision to admit) with no hospital admit note do we only bill the office visit? does he need to write an h&p (we can then combine with the OV) to bill the 99221-99223?

thanks so much


Best answers
if the pt was seen @ the office and than admitted to the hospital, the office visit is considered bundled into the initial hospital care service. All services given @ the office may be taken into account when the appropriate level of hospital admission is chosen. yes! You do need the H&P form for that. I hope that I was able to help