Wiki Opinions please about HP level

[coder25]

I think I know the answer to my question, but I just want to double check.

A resident handwrote H & P exam on paper, however doctor did not cosign it.(The patient was admitted at 2:00 a.m) (there is no formal dictation in hospital system and my doctors refuse to dictate one). There was a note done the same date, however, the time was 7:20 a.m. and there the doctor cosigned that note done by the resident.

On the handwritten H & P note, there is only 3 elements in the HPI. The hospital note can be billed out a level 2.

Am I correct in my thinking, that I can only bill out the subsequent visit and not the initial H&P, as I do not have four elements needed for a level 1 admit????

Thanks in advance for your help!

 

[LLovett]

From a leveling stand point, you can bill it as a 99499 and send the notes.

From a compliance stand point, and I could be wrong residents aren't a daily part of my big picture just yet, I don't think you can use it at all if the supervising physician did not sign off on it.

Laura, CPC, CEMC

 

[FTessaBartels]

Teaching physician rules

Without seeing the actual notes it's difficult to give you an accurate response.

For government payers (Medicare and Medicaid) the teaching physician MUST show presence and participation in the care, and agree with the documentation done by the resident. E.g. "Patient seen and examined with resident. I participated in the exam, history and medical decision making and concur with the note as documented by Dr Resident." Of course Dr TP signs/dates.

For most commercial payers there must be an indication of the supervising teaching physician (supervision does NOT need to be personal, bedside ... can be by any means of communication ... i.e. phone or fax). E.g> resident writes - "discussed with Dr Teaching Physician." and Dr TP signs/dates.

The INITIAL hospital visit by your teaching physician was apparently the one done at 7:20 a.m. If that note references any of the H&P ROS and PFMSH you can use that information as well. Your level of service is dependent then on this possible combination of information.

If your teaching physician was, in fact, present for the 2:00 a.m. admission, the TP should go back and sign/date that note. (Unless this scenario was months ago, you should be okay) If you have any additional HPI elements in the 7:20 a.m. note you can then use both notes combined to bill out your initial hospital visit.

Otherwise, like Laura said, you'll probably need to use 99499 and send the records along.

Hope that helps.

F Tessa Bartels, CPC, CEMC