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Thread: Office visit -vs- Direct admissions

  1. #1

    Default Office visit -vs- Direct admissions

    AAPC: Back to School
    Could someone please help, A Orthopeadic Surgeon does a comprehesive ov on a patient and then decides that a direct admission to the hospital is the way to go how do we coded it. Do we code the OV or the Direct admission?
    Thanks for your help.

  2. #2
    Join Date
    Apr 2007


    As payors will only pay for one E&M per day, our clinic bills the admission as the IVUs are higher than a typical New or Est Office E&M. Any information obtained or results of the examination performed in the office can be added to the doctor's admission note for the hospital and used with picking the appropriate admission level to be billed.

  3. #3
    Join Date
    Apr 2007
    Evansville Indiana

    Default admission

    If you are going to bill the admission, just remember that the physician must actually go see the patient in the hospital that day. If they don't see the patient until the next day, you could bill an OV for the first day and an initial encounter the next day. You cannot bill the initial hospital encounter without face to face at the hospital.

  4. #4


    I recently attended a seminar for General Surgery and asked this same question. It was a hot topic in our office a few months back. The answer I got was "code where the patient landed". In otherwords, if the patient was seen in the office and sent to the hospital and a true admission was done by your physician, then you code the admission. Same for Observation at the hospital. If the patient wasn't actually admitted but was seen in OBS by that physician, code for the OBS.

    Hope this helps some.

  5. #5
    Join Date
    Apr 2007
    North Carolina


    Just to add what Jennifer has already said...

    When the patient is admitted to the hospital via another site of service (e.g., hospital emergency department, physician’s office, nursing facility), all services provided by the physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission


  6. #6
    Join Date
    Apr 2007
    Phoenix, AZ


    Okay, having a senior moment (WAY before my time)! My MD saw patient in office for a-fib and sent patient to hospital. He used his office notes as the H&P. Does he need to dictate a note at the hospital and reference his office notes?

    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

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