Coding Nuggets were provided by Jeannie C. Cagle, R.N., CPC, a senior consultant of The Coker Group with more than 20 years experience in clinical health. The Coker Group is an SMA approved partner.
November 2007
Question
Our physician practice is owned by our hospital. Because we are owned by the hospital, we have access to their system and we can pull OP notes; F/U reports, and also H&P reports. When a patient comes to see my doc, and the doc decides he is going to do surgery at the hospital for that patient, he will not dictate an office note- 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. Since I have access to the hospital system, I pull this report and put it with my encounter and use this as my office visit charge. Is this appropriate? Do you think it is a compliance issue? We were told recently at a seminar that is not correct!!! The doc must dictate his own office visit note for my charge in the office- I can't use the H&P dictated for the hospital.....as this is part of the Global Surgery Package. I have tried to find a policy regarding this, and I can't! Can you help???
Answer
When your doctor sees the patient in the office, there should be a note that describes what happened during that office visit for the billing code to be supported. If the physician wants to later use portions of information gathered at that visit (like the past medical, social and family history) for the dictation for the H&P needed for the surgery admission (assuming it is done within several days), he can do that, but I agree that the H&P dictation would not suffice for the office note and the H&P is considered part of the payment through the surgical global package. In essence, using the H&P documentation as the office note that you bill for would be a compliance issue. I’m wondering how the wording of an H&P would work for an office visit anyway – the history of the present illness would describe the reason for the hospital admission and subsequent surgery, yet the patient was not admitted that day.
Question
If our physician does an office visit and decides the patient should be admitted to the hospital right away, he’s been calling the hospital dictation system from the office and dictating an initial hospital note since we know he can’t bill both the office note and the initial hospital visit on the same date of service. He then sees the patient the next day. Is this correct?
Answer
One principle to keep in mind is the phrase “face to face in the right place”. Your physician can’t bill an initial hospital visit code unless he actually sees the patient in the hospital that day. And the dictation for the note should match the date of service for when the patient is initially seen in the hospital. So he could bill for the office visit for the day he saw the patient in the office and then bill the initial hospital code the first day he sees the patient in the hospital. Remember, that if another physician from his group sees the patient first in the hospital, then he or she would do the initial hospital visit note.
