Urology Coding Alert

Question: Our physician practice is owned by our hospital, so we have access to their system. When a patient comes to see my physician, and he decides to do surgery at the hospital, he will not dictate on office note. Instead, he will note that he will dictate an H&P for the hospital, indicating to me that I am to use the dictation of the H&P to charge for the office visit for that day. I pull this report and put it with my encounter and use this as my office visit charge. Is this appropriate?

North Carolina Subscriber

Answer: Although your physician's rationale and his desire to decrease his paperwork is understandable, CPT and CMS rules indicate that documentation must be present and available for each encounter if you want to bill for each service. In this case, your urologist will definitely need documentation of his office visit if he wants to report the service.

How it works: Most likely, you will not code for the hospital admission note because this represents a hospital-required administrative history and physical examination. No doubt both his office and initial hospital notes will be similar, but each note must be written individually and available for review if carriers request them.