Wiki History and Physical date requirements

[Dilliemr]

I'm asking for any input on this subject and please document any reference information that I can bring to my manager to back it up.

My question is can a physician use an H&P that is over 30 days old prior to admission for surgery? I've always been told that it can not be used even if the physician documents no changes with the date of admission. I'm being told different now. Any input would be appriciated.

 

[FTessaBartels]

Used for what?

Used for what? "An H&P" is not a recognized E/M code, but is a requirement of all facilities before admitting a patient. That documentation is frequently what is used to code the "Initial Hospital Visit" (whether inpatient or observation/outpatient procedural short stay). So ...

Are you asking whether you can bill an Initial Hospital Visit when the physician indicates that the H&P performed mm/dd/yy (which is more than 30 days prior to admission) has not changed? Answer - Moot point. If it's a scheduled surgery, the admission for surgery is bundled into the surgical fee (i.e. your decision for surgery occurred at a previous visit, probably when the H&P was completed).

OR ... are you asking whether the HOSPITAL will accept an H&P that is more than 30 days old if the physician indicates s/he has reviewed and there are no changes? Answer That will depend on the facility. Ours will not accept it.

Hope that helps.

F Tessa Bartels, CPC, CEMC