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Using a Dictated Office Note for an Admission H & P?

  1. Default Using a Dictated Office Note for an Admission H & P?
    Medical Coding Books
    Can someone please help?

    Is it appropriate for the Physician to use a particular office note/dictation from an office visit which was billed already for this office visit. In the note a decision is made during this particular visit to admit the patient for further work up/care at a later date.

    On the later date which would be the day of the hospital admission, an History & Physical is required by the hospital for the admission. The Physician uses the note from the previous office visit with a satement that states "reviewed and no change" and dates it.

    Would this be acceptable to capture as a separate charge for the H & P.

    Or, if there are any acceptable similiar examples can you please list them.

    Thank you

  2. Default
    No.. you can not bill for the note that was just review and resigned... you probably could use it, but can not be reimbursed for it twice... MD must dictate new note or H & P for the date of admission...

    Unless it was within 24 hours before and you billed it with a 57 modifier, but no double billing

  3. Default
    Thank you for responding....I was thinking exactly what you stated. I am glad you were able to make it clear.

  4. Default
    If there are any documentation related to my question/topic on a credible website( i.e., CMS/Medicare) can you please share this information with me.

    Thank you

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