# Hospital H&P and consult documentation



## crhunt78 (Nov 24, 2008)

I work for 3 general surgeons.  One of my docs does not like to write in pt's charts, he dictates everything.  That said, my dilema is this:  He will dictate a hospital H & P for a surgery he is going to do in 3 weeks to a month and in the pt's chart at our office he just writes, "See Hospital H&P."  Then he wants to charge a consult.  I know that this is incorrect documentation but am having a VERY hard time explaining to him that he has to dictate a letter to the requesting physician and that the H&P must have the same date on it as the consult charges we submit.  I have looked on the American College of Surgeons website for help and even called them but they just confused me even more than I already am.  Can someone please help me with this?  I desperately need to find something to give this doctor IN WRITING that says he cannot use the H&P for his consult dictation.  HELP!


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## Pam Brooks (Nov 25, 2008)

Our local CMS carrier (NHIC) has a nicely written E&M documentation guidelines manual that spells out these issues very nicely.  Check with your carrier, it's likely that they have the same.    
Pam Brooks, PCS, CPC


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## FTessaBartels (Nov 25, 2008)

*What does the H&P actually say?*

What does the H&P actually say?  Did he dictate that he is seeing the patient in consultation for x problem at request of PMD? Did he use the date of service of the office consult visit?  (e.g. date of service 10-22-08 / date of admission 11-08-08)  Did he request a copy sent to the requesting physician?  (Our hospital's dictation system allows this to happen.)  If a copy isn't being sent automatically can your doc at least dictate a short - "Dear requesting doc ... thanks for consult ... surgery is scheduled, please see attached dictation for details." (and then attach the dictated note)

I understand your frustration. I also understand that the physician doesn't want to have to dictate all the information a second time. That being said, however, I'm willing to bet that the hospital still requires him to review and update the 3-week-old H&P (our hospital wants an H&P completed no earlier than 48 hours prior to admission).  

If you don't have access to the hospital record to get a print-out of the dictation ... do what you have to to get that access! You absolutely have to have that information in order to make a final determination of what can be billed. 

Good luck

F Tessa Bartels, CPC, CPC-E/M


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