Question: Our surgeon admitted a patient but did not dictate an H&P. On the same day, he performed a laparoscopic appendectomy. In the operative report, he did dictate intraoperative findings and a "Brief Clinical Note." Can I use this information in place of the H&P?
Michigan Subscriber
Answer: Unfortunately, if the surgeon does not dictate a complete E/M note -- including history and physical (H&P) -- you cannot report the E/M service.
In other words, you can't code what isn't documented.
Each procedure code has an inherent E/M component, according to CMS and CPT instructions. The intra-operative findings and "brief note" your surgeon dictated as part of his operative note would qualify only as this inherent E/M for the laparoscopic appendectomy (44970, Laparoscopy, surgical, appendectomy).
Had the surgeon documented a full H&P, the pre-operative exam may have qualified as a separate E/M service, which you might have reported with modifier 57 (Decision for surgery) in addition to the surgical service.
