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Documentation Tips for Hospitalists

Great comments for documentation:

-Review of prior records should be documented.
-For higher acuity levels, the ROS (Review of Systems) should include a review of 10 or more systems or note that all others were reviewed and negative.
-Separate the ROS statement from the HPI.
-Address those systems with positive findings individually.
-Physicians should note discussion of patient history or case with other physicians and include a brief note as to the content of the discussion.
-Direct visualization of diagnostic tests should be clearly documented. When reviewing another physician’s interpretation it should be noted as such. The time spent discharging the patient should be clearly noted on the dictation.
-Physicians should clearly dictate the date for the service they are documenting.
-Observation notes should include time patient was placed in observation and time patient was discharged from observation status. In addition, physicians must record their efforts throughout the observation process.
-Consultations are no longer recognized by Medicare. However, document any consultative service. The first should be coded as initial visit, each subsequent consultation would be billed as subsequent visit for Medicare patients. The consultation codes DO apply for non-Medicare patients.
-When patients meet clinical criteria for critical care, note critical care time.
-Consider billing EKG interpretations when performed and well documented.
-Consider billing for smoking cessation counseling.
-Note admit to inpatient or place in observation status to differentiate inpatient from outpatient service. This is a target area for Medicare.

As there are only three Initial Hospital Care levels, omission of the required 10 system ROS and/or 8 Organ System PE results in down coding to the lowest level of Initial Hospital Care.
Subsequent Hospital services for patients who are not responding as expected but not experiencing severe medical problems are generally coded at the 99232 moderate level.
For those patients whose hospital stay is complicated by medical problems, adverse reactions to medications, new problems, etc., 99233 high service level is appropriate.
For those patients who are generally improving with no complications, the 99221 straightforward/low level is generally appropriate.