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Direct Admission from the Office

  1. Default Direct Admission from the Office
    Medical Coding Books
    We are having a debate about whether the Office physician can do the following:
    If the Office Physician performs the Initial IP visit, can they use the Office HPI for the Initial HPI or do they have to perform one from the POS that the Initial visit is charged. CPT says that it is all included but we want to make sure that it means whether they can use the Office HPI for the initial or is it informational only as backup?

    Please send back up information other than page 12 or the E&M guidelines because that is what is confusing some of us.

    Anne Alsabrook

  2. #2
    Milwaukee WI
    Default Well that depends ...
    Part of the answer depends on exactly what your question is.

    For documenting the level of service of the initial hospital visit 99221-99223 ... it doesn't matter what form you use or where the piece of paper is located (office chart, hospital chart) or how you combine the various pieces of paper. As long as, if asked, you can produce the documentation that supports the chosen level of service.

    The hospital, however, may require that you use and complete their own H&P form. That doesn't make it separately billable, it's just the rule of that facility for physicians granted privileges there.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 09-15-2009 at 01:53 PM.

  3. Default
    If our provider is planning to take the patient to the OR for a procedure, he/she will state in their record "I would also like to use this document for the H&P". It won't be separately billable, but it would satisfy the hospital's requirement for an H&P.


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