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Thank you 
Thank you
Patient came from ER for CHEST PAIN and no assessments have been done yet to determine exact dx.
H&P Provider documented:
# TIA VS SYNCOPAL EPISDOE MUST RULE OUT (CARDIAC ETIOLOGY RECENT + LEXISCAN)
#AKI LIKELY PRE RENAL (GFR 58 AND CR 1.07 ON 6/22/18)
#NON-AGMA (BICARB16)
#HTN
# LACTIC ACIDOSIS
Do i code the rule out dx as well as chest pain? or just chest pain and everything else provider documented. HELP!:confused:
EX: HP completed on 03/12/18, but there is no admit/observation status until 03/13/18
CPT : all EM services provided by the physician in conjunction with the admission are considered part of the initial hospital care
when performed on the same DATE as admission.
So the provider is actually performing the HP, before the date of admission. We cannot consider it part of the initial care, because it was not performed on the same DATE as admit
The question is…
1. are the consult and progress notes considered post op after the re admission?