Wiki Question about E/M admission

[coder25]

Hello all,

Not sure what to do with this Medicare patient. If the patient was seen in the office and then directly admitted to the hospital the same day, but the HP was dictated by a resident with no doctor attestation, can I bill out the HP or can I only bill out the office visit???

Of note, the patient did have an I&D during the hospital admission.

Thanks so much for your help!

Peggy

 

[geigerk]

We need more detail. Obviously, you need preceptor attestation, but you do have 24 hours to get it by Medicare rules. The preceptor states in his attestation that they have seen & examined the patient....etc. In order to bill the I & D, the preceptor must have been present during the procedure.

Otherwise, you would bill the office visit for that calendar date and H & P (Initial Hospital Care) would be billed the initial day the preceptor sees the patient, the next day.