Wiki OV Decision for surgery and H & P

[Krisnva]

PA-C or MD sees new patient or pt for a new problem in office and after exam, xrays, etc decides pt needs surgery ASAP (within 24 hours).

I know an Office Visit can be charged with modifier 57 for the decision for surgery.

My question is regarding the documentation. The provider should dictate an office note to warrant charging an

Office visit and then dictate the H& P for the surgery as required by hospital. Is this correct?

Or can the H & P be used for both the H & P and the Office visit charge.....This is what the PA-C wants to do..instead of dictating twice.

 

[Treetoad]

The way I understand it, the same documentation can be used for both. Our providers state in the documentation, "This will also serve as the H&P for the patient's upcoming surgery". It can only be billed once.

 

[1073358]

Mine use one note for both. Usually dictates a blurb on the clinic line, leading the reader to see note dictated on the hospital line to serve as HP