veeramani14
Networker
Hello all, can anyone clarify this.
For inpatient admissions we have a house physician overnight service. When a patient is admitted the house physician completes and documents the full history and physical. When I see the patient the next day I do a complete history and physicaI and then cosign the house physician's history and physical. I then write a progress note and code a 99221-99223 for the day I see the patient.
Am I documenting the encounter and coding it correctly?
If not:
Do I need to write an addendum to the house physician's history and physical and if so what is needed in the documentation?
Or do I need to write a new complete history and physical?
Thank you,
Veera
For inpatient admissions we have a house physician overnight service. When a patient is admitted the house physician completes and documents the full history and physical. When I see the patient the next day I do a complete history and physicaI and then cosign the house physician's history and physical. I then write a progress note and code a 99221-99223 for the day I see the patient.
Am I documenting the encounter and coding it correctly?
If not:
Do I need to write an addendum to the house physician's history and physical and if so what is needed in the documentation?
Or do I need to write a new complete history and physical?
Thank you,
Veera