Office visit turned into H&P for Hospital Observation

Our patient presented for a 2 week post operative follow up with her PCP. The PCP office setting is a Hospital Based Primary Care Office.

The follow up visit turned into a H&P with the patient being admitted to the Hospital for Observation with the PCP being the admitting Physician.

I am not clear what CPT® is appropriate for this encounter as it is my understanding that E&M services on the same date related to the admission to Observation should not be reported separately, yet I am being told that the PCP should bill for the H&P done in the office. This is a Medicare patient.

What are your thoughts on this?

re: Office visit turned into H&P for Hospital Observation

If they are being admitted to observation then you would bill the appropriate level of observation. If this is a complication of the surgery then it would not be billed at all.

re: Office visit turned into H&P for Hospital Observation

You cannot bill and office visit on the same day as an admission to the hospital. Also, since observation is an outpatient status you can combine the documentation of the ov and the initial obs visit to determine one code if it is the same physician/group. This is especially for a Medicare Patient.