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  1. #1
    Question Cpt
    Exam Training Packages
    Do you know if there is a CPT code for JUST a History and Physical?

    Here's my situation…

    Pt presented to the ER with a hip fracture. Medically, there was nothing we could bill for. Pt has HIV but that is irrelevant to the fracture. Pretty much, all that was done was the H&P. I'm just wanting to know if there is a specific code for JUST that…

    We cannot bill for the fracture, we are a hospitalists group.

  2. #2
    There was no MDM at all?

    I would go with 99499 and send the notes.

    Laura, CPC, CEMC

  3. #3
    I bill for hospitalists, too. Can you post the note? There must have been somewhat of an exam. If the patient was admitted you could use a subsequent visit code or was it just an observation? There is an observation discharge code if your docs sent him on his way or transferred care to another dr. the note would be essential before saying.

  4. #4
    Duluth, Minnesota
    I'm curious - why'd the patient present to the ER in the first place?
    how'd they know there was a hip fracture or HIV if they didn't do some sort of exam? (did they just take the person's word for it? "yeah, I have HIV and a fractured hip"???) Not that the patient would lie, but - I'm just thinking they had to have done at least a very minimal exam to even determine that "there wasn't anything they could do for the patient"

    wow the things we come across hey!!
    Donna, CPC, CPC-H

  5. #5
    Milwaukee WI
    Default Initial Hospital Visit
    I'm confused ... did your hospitalist admit the patient? If so, then code the appropriate Initial Hospital Visit (or initial Observation) code.

    Or are you saying that the hospitalist was used to merely fill out the required paperwork? Any H&P I've ever seen has sections for history, exam and plan. How'd the hospitalist get this info to complete the form without seeing/examining the patient?

    If orthopedics admitted the patient ... they should have done the H&P.

    This is definitely a conundrum.

    F Tessa Bartels, CPC, CEMC

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