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Billing for Resident H&P

  1. #1
    Question Billing for Resident H&P
    Medical Coding Books
    Hello,

    I have been billing for a short time for our resident program. We are starting to have an issue with our supervising physicians not signing the resident's H&P for the Attending Supplement. My supervisor says without that signature, we are unable to bill for that H&P. Our billing office is looking at the first progress note from later on in the same day and counting that as an H&P if the overseeing doc signed that. What is the accurate way to do this? Are we able to bill the H&P this way, or only the subsequent visit later that day? Thanks!!

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Initial Hospital Visit
    There is NO CPT code for "H&P" ... look it up.

    There IS are CPT codes for Initial Hospital Visit .. i.e. the first time the provider sees the patient in the hospital. So if you are coding the Initial Hospital Visit based on the teaching physician's handwritten note, then you are doing that correctly.

    HOWEVER .... you CANNOT use any part of the resident's note unless the teaching physician has also signed that note ... or at least referred to the ROS & PFSH from that resident's note in his/her handwritten note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Default
    We have residents in the office. How much documentation may the resident record in the EHR? PFSH and ROS for sure. HPI and exam, too? May they document the whole note with the supervising doc's appropriate comment?

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