You will bill the initial hospital visit based on the documentation you DO have. If you need it, you can use the resident's documented PFSH and ROS if your physician has countersigned the resident's paperwork (EVEN without attestation statement).
CPT clearly tells us that if the patient is admitted to the hospital in the course of an encounter in another place of service, to code only the hospital admit. Don't let the source of the paperwork throw you. BUT I would make sure a copy of the office note is put in the patient's hospital record in case of future audit.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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