# E/M using hospital H & P



## pamfran (Jan 29, 2010)

A surgeon we have wants to use the H & P she dictates for the hospital admission of the patient, the physical part, in her office visit note same day saying under PX, see Admission H & P, can she do this?  There is nothing to code on the ov note for physical exam but there is on H &P. She does not want to dictate this twice, is this acceptable?


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## mitchellde (Jan 29, 2010)

you can only bill for either the admit or the OV not both.   And if the decision for surgery has been made in a previous encounter, it highly likely you will not be reimbursed for the admit and should not be charging for it since it is preop.


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## LLovett (Jan 29, 2010)

I want to add one thing, while you only get to bill for one, you do combine the documentation in order to level.

So she would get credit for her exam without dictating it twice. You just need to be careful and not unbundle services from the surgical package like Debra said.

Laura, CPC, CPMA, CEMC


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## FTessaBartels (Jan 29, 2010)

*It's just a piece of paper*

Debra is absolutely correct.  The visit may or may not be billable (might be covered under global surgery package).

That being said, I'd like to address your specific question - can you use the dictated H&P as documentation for the office visit?  

Our practice is hospital based - i.e. we see all patients in a hospital outpatient clinic. 

I have one provider who likes to use the hospital's H&P form for *all *new patients - it's four pages long and has all the spaces / prompts for the physician to ensure a complete report (as needed, of course).  It doesn't make any difference that the piece of paper used is titled "Admission History and Physical"  - it is still the record of the "office" visit for that patient. 

I have also seen cases where a new patient comes for a consultation with the surgeon, who makes the decision for surgery at that initial office visit. If the patient can be scheduled within the next few days, the surgeon will usually dictate the hospital H&P right away (saves two dictations), but the *date of service *is still the office visit, and the documentation supports the appropriate level of new patient office visit. 

So, yes, it is *possible *that what your surgeon is documenting is perfectly fine.  But read Debra's comments again ... if the decision for surgery was made at a previous visit and the only reason for THIS visit is to get the H&P done before the patient shows up on the day of surgery, this is NOT a billable service. The reimbursement for the surgery itself includes payment for the necessary pre-op H&P. 

Hope that doesn't further confuse you. 

F Tessa Bartels, CPC, CEMC


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## pamfran (Jan 29, 2010)

Thank you everyone. If there is any thing in writing that I can use to corroborate this for my boss, this would help me.  No, she is not doing a separate visit just for H & P. She is seeing pt usually referred and deciding to do surgery, then dictates H &P to  hospital on same DOS as office visit. Hospital H & P has same date of dictation as the OV, but the hospital puts the admission date on the dictation on the H & P just before the surgery.  The surgeon want us to use the PX on the H & P for the physical exam for the OV.  So H & P says dictated say 1/16/10 and the hospital puts admission date on dictated copy as 1/28/10 but dictated date on bottom of H & P is date of OV

A little confusion but if we can combine these it would save a lot of time on everyone's side.


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## FTessaBartels (Jan 29, 2010)

*Three (or four) dates*

Depending on your dictation / transcription sytem and how it is set up you might have four dates on any given document.
Date of Admission
Date of Service
Date of Dictation
Date of Transcription

The first two are what you need.  In our system these two dates are in the "header" of each transcribed note.  For most H&Ps they are the same date. But they CAN be different.  You need a date of service specified as 01-13-10 and a date of admission specified as 01-28-10 (for example)

The date of dictation and date of transcription - in our system - are listed at the bottom of the page, underneath the providers name.

Now if your system doesn't have a way to do this the easy fix is to have your surgeon add a quick phrase at the beginning of the H&P "Patient seen and examined in office on mm/dd/yy, with resulting decision for surgery."

Hope that helps.

F Tessa Bartels, CPC, CEMC


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