Medical Billing Advisory: Eight Quick Tips for Error-Free Hospital Documentation

Betsy Nicoletti, M.S., CPC August 19th, 2011

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Avoid coding errors for hospital services with this informative article from Betsy NicolettiThere’s no doubt: there are more coding errors for hospital services than office services.  For some physicians, the volume of hospital services is so much lower, they never learned the guidelines as clearly.  But even among hospitalists, who care exclusively for hospitalized patients, the coding isn’t perfect.  Just a few changes, however, can dramatically change that picture and improve the accuracy of hospital coding.

1. Don’t forget family history in the initial hospital services notes

Level two and three inpatient and observation admissions require past medical, family and social history and ten systems in the review of systems.  A comprehensive exam is also required.  Without all of those, the admission audits at the lowest level, no matter how sick the patient is.  Find a template, and use it when dictating the admission.

2. If you can’t get a history from the patient, say so

Some patients are sedated, intubated or confused when admitted to the hospital.  If unable to obtain a history, document the history from the family or caregivers, emergency medical responders and medical record.  Then state, “I am unable to obtain a complete history and review of systems because the patient is sedated.”

3. For rounds, document the reason for the hospitalization

A subsequent hospital visit is in the middle of a chart that tells the entire story of this episode of care.  Because of that, many physicians don’t describe the reason for the hospitalization for each visit, finding it redundant.  Auditors say, “Each visit must stand on its own.  Without a reason for the rounds noted each day, the visit isn’t billable.”  A prudent recommendation: briefly note the reason for the admission each day.  “Follow up: MI” or “Follow up COPD” is sufficient.

4. “No complaints” doesn’t make an HPI

After briefly noting the reason for the admission, describe how the patient is doing.  Document the patient’s symptoms related to the admission.  Document pertinent negatives related to their conditions.  If the patient is truly without any complaints or symptoms, document the events of the previous 24 hours as described by the nurses or patient’s family. 

5. Just say no to post op care

Hospitalists are not house staff.  Surgeons are paid a global fee to provide post op care related to the surgery, including pain, wound care, fluids and post op instructions.  A medical physician may see the patient to manage their medical conditions if there is medical necessity for the visit.  Document the status of the patient’s chronic problems or their symptoms in the subjective portion of the note.  If the entire HPI is about the surgical follow up, there is no medical necessity for the medical specialist to see the patient.  Similarly, the assessment and plan documented by the hospitalist should address medical problems. 

6. If the visit is defined by time, describe time in the note

Document time in the medical record for discharge code 99239, critical care and prolonged services.  (Medicare requires start and stop time for prolonged services.)

7. The patient’s problem list is not an assessment

Too often, the assessment is a long list of problems and conditions, some current, some not.  Which problems were addressed by this physician at this visit?  The assessment should consist of those, along with the plan.  Some active problems managed by other specialties are included in the assessment “Urinary retention, appreciate Urology’s help,” makes it clear that the physician writing the note is not managing that condition.

8. Don’t copy and paste from day to day in your  Electronic Health Record (EHR)

While it is true that the Office of Inspector General is concerned about cloned notes, the clinical problems with copying the notes from rounds from one day to the next is that another clinician can’t tell what happened at that visit.  A too common practice is to open yesterday’s note and edit it.  When this happens, it is impossible to separate today’s history, assessment and plan from yesterday’s or the day before.  There are often inconsistencies as a result, as in the following history:  “Patient is intermittently confused but more alert.  Patient lethargic and minimally responsive.”  However tempting, don’t copy yesterday’s note.

Adopt these practices and your coding error rate will plummet.

Betsy Nicoletti Gives 8 Tips for Error-Free Hospital DcoumentationBetsy Nicoletti, M.S., CPC, is the founder of Codapedia.com, a wiki for physician reimbursement. She is a nationally known speaker and consultant, and can be reached at www.mpconsulting.org. You can hear Betsy speak in a complimentary recorded webinar presented by Kareo on “What You Can Do to Prepare for Medicare Payment Reductions.” Recently, Betsy wrote Medical Billing Advisory: Hold Those Hospital Charges!

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