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Admission notes

  1. #1
    Default Admission notes
    Medical Coding Books
    If the Doctor does the admission notes on one DOS, and then the Nurse Practitioner does the Initial on another DOS, who should bill for the admission 99221-99223?

    Thank you,

  2. #2
    Milwaukee WI
    Default Not sure I understand
    Do not confuse the hospital's requirement for an "official" H&P with the initial hospital visit.

    The initial hospital visit is coded for the provider who FIRST saw the patient IN the hospital, regardless of whether that documentation is in the form of an H&P or in the form of a scribbled note.

    Who saw the patient in the hospital first and admitted him/her? If the physician saw the patient in the hospital on day of admission, they the physician's documentation serves as the basis for chosing the level of Initial Hospital Visit 9922x.

    On the other hand ... if the physician saw the patient in the office, and recommended hospitalization, dictating an "admission" note ... but did NOT see the patient in the hospital Face-to-face on that date of admission, then you code on the documented level of office visit. The NP, then, would be the FIRST provider to see the patient in the hospital on the next DOS.

    Not sure if that describes what happened ... but I hope it helps.

    F Tessa Bartels, CPC, CEMC

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