If the surgeon who will be performing the surgery is ALSO in your practice/specialty, then you will code ONLY the hospital admission, with decision for surgery. You roll all the work documented (including the office note and any ER note if done by your surgeons) into one level of service. You should have a policy/protocol in your practice that determines WHO gets credit for this E/M. Since it will be either an Initial Inpatient or Initial Observation code, I would say the surgeon who is on call at the hospital should probably get the credit, but if the clinic doctor is actually going to go to the hospital to meet the patient there, and will perform the H&P, then that doctor can get the credit. Just be sure you have a protocol in place and you follow it strictly. (And since this sounds like a decision for surgery, don't forget your modifier ... either -57 for major surgery, or -25 for minor)
Hope that helps.
F Tessa Bartels, CPC, CEMC
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