tci General Surgery Coding Alert - 2009 Issue 1

Reader Questions: Separate E/M Requires Complete Documentation

Question: Our surgeon admitted a patient but did not dictate an H&P. On the same day, he performed a laparoscopic appendectomy. In the operative report, he did dictate intraoperative findings and a "Brief Clinical Note." Can I use this information in place of the H&P? Michigan Subscriber Answer: Unfortunately, if the surgeon does not dictate a complete E/M note -- including history and physical (H&P) -- you cannot report the E/M service. In other words, you can't code what isn't documented. Each procedure code has an inherent E/M component, according to CMS and CPT instructions...

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