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Thread: Obs to Inpt

  1. #1

    Default Obs to Inpt

    AAPC: Back to School
    If a physician does an H&P when the pt is admitted to obs, do they have to do another H&P when the pt is admitted to inpt status? How do they document the initial visit as inpt?

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default H&P

    The "H&P" is a hospital required document. It can be used as documentation to support the provider's initial hospital visit. Doesn't matter what form your documentation takes, as long as you have documentation that meets the criteria for the type and level of service you are coding.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007
    Duluth, MN


    depends on if they are separete dates of service if so and the md is the admitting physician then I do believe you can charge both. If they are on the same date of service then you can only bill the initial hospital visit. Hope that makes sense. And as far as the documentation either way if they were going to charge for it they would need it documented in order to get the level of service for the code. So yes they would need to either amend the Observation documentation or dicatate a new one (if on same day) and dicatate a new initial hospital visit if it is on a separate date.
    Last edited by twosmek; 04-08-2010 at 10:21 AM.
    Tina Wosmek CPC, COSC

  4. #4


    Thank you both. I want to make sure I understand. For example, pt admitted to Obs on Monday, the admitted to InPt on Tuesday. Which is correct?
    (1)The physician does the H&P on Monday for the Obs, and documents the services done on Tuesday for initial visit, but not another H&P for Tuesday.
    (2)The physician does an H&P and additional documentation for the Obs on Monday, then documents the services done on Tuesday for initial visit, but not another H&P for Tuesday.

  5. #5
    Join Date
    Apr 2007
    Duluth, MN


    In order to be able to charge both the Observation admission on one day and then a hospital admission the next day he would need to have two separate documentations that meet the criteria for the codes used.

    Look at the notes in Your CPT code book. The information regarding it is in there under the Intial Observatin Care and again under Intial Hospital Care.

    My common sense tells me that there had to be a good reason the status changed and he/she would definately need to document that.

    Hope that helps. I wish I had an example but all mine are ortho cases so they usually stay as observation or are admitted right away.
    Tina Wosmek CPC, COSC

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