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inpatient e/m

  1. #1
    Default inpatient e/m
    Exam Training Packages
    per federal regulations, if a patient is admitted within 30 days of their last admission, for similar diagnosis, the initial H&P may be used with an admit note written updating the patient's course of illness and new examination findings since that time.

    my question is, can i use the initial H&P combined with the new info to assign the initial inpatient e/m level for the new admission?

  2. #2
    Milwaukee WI
    Default History yes, exam & MDM no
    Yes, you can use the history from the first H&P (properly noted in your current documentation as to source). Your exam and MDM need to stand alone.

    F Tessa Bartels, CPC, CEMC

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