E/M Coding: Point of Controversy When There’s No H&P or There's No Up-To-Date H&P


The Apex Medical Center has hired a specially trained nurse practitioner to be a hospitalist. Part of the NP's duties involve performing pre-surgery history and physical if there are any patients scheduled to receive surgery for whom there is no H&P or there's no up-to-date H&P. The hospital is coding and billing for the services of the NP on a professional basis. So what happens? And this is not that unusual to everyone. What happens is the patient presents, the nursing staff checks to see if they have an up-to-date H&P, they may discover that there's no H&P or that there's no up-to-date H&P. And for some hospitals, this can become a point of controversy.

If there is no H&P or there needs to be an update to history and physical, then the nurse
practitioner takes the patient aside, performs the history and physical, clears the patient for the surgery.

The surgery is performed by the surgeon then both the surgeon and the hospital will bill for this service. Now, this raises an interesting question because the hospital is coding for the surgical procedure and also coding for the E/M level for the pre-surgery H&P which is fine, nothing wrong with that. Then the hospital will use the -25 modifier on the E/M level to separate it from the surgical procedure.

Now, what you have to keep in mind, what's unusual here is that the hospital has one claim form with two different providers. Two different people have performed two different services, but we still put it on one claim form.

On the physician side, it's always the same physician who will be coding the E/M as the surgery.
Well, there could be some unusual circumstances but on a professional claim, the physician performing the procedure would have been that did some sort of an E/M level in addition to the surgery.

So keep in mind, on the hospital side, where we code for resource utilization, this means that we can have more than one practitioner doing something and we will code both services on the same claim form.

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