Rochelle Fillyaw
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I have a question in regards H & P documentation.
Example:
We schedule a patient to be admitted to the hospital to have a sotalol infusion done. Can the provider use the last office visit as the H & P and document on it "no changes" sign and date and bill a 99221? Does a new document need to be created? (admit would not be on the same day as the office visit). Would the following be enough for a 99221
Date:
HPI: Reviewed from visit of __________. HPI essentially unchanged except for
ROS and Comp. History—Reviewed from stated visit, history essentially unchanged except for
Physical exam- Vitals from intake reviewed. Exam from stated visit essentially unchanged except for
Impression: AFib.
Plan: Tikosyn/ Sotolol Induction
Total time spent on today’s admission ___________. More than 50% of the time was spent on coordination of care, including orders,
reviewing labs/ diagnostics and counseling patient on risks and possible adverse events of the medication.
See previous office note
Phys Name/sig. /date
Thank you in advance for all your help.
Example:
We schedule a patient to be admitted to the hospital to have a sotalol infusion done. Can the provider use the last office visit as the H & P and document on it "no changes" sign and date and bill a 99221? Does a new document need to be created? (admit would not be on the same day as the office visit). Would the following be enough for a 99221
Date:
HPI: Reviewed from visit of __________. HPI essentially unchanged except for
ROS and Comp. History—Reviewed from stated visit, history essentially unchanged except for
Physical exam- Vitals from intake reviewed. Exam from stated visit essentially unchanged except for
Impression: AFib.
Plan: Tikosyn/ Sotolol Induction
Total time spent on today’s admission ___________. More than 50% of the time was spent on coordination of care, including orders,
reviewing labs/ diagnostics and counseling patient on risks and possible adverse events of the medication.
See previous office note
Phys Name/sig. /date
Thank you in advance for all your help.