Billing E/M for Hospitalists

bevneal

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I have a question : when coding for subdays for hospitalist, it has always been my understanding that per guidelines the CC should always be listed or easily found in the subjective portion. I have recently been told that it is not required and only use the physicial exam and the MDM to determine the level of service. Since only 2 of 3 are required. I am confused, if 2 of 3 are required, would you not still need all three to make a decision?

Can anyone give me an answer and also documentation regarding this?

Thanks at the point of despiration
 

bevneal

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yes Medical necessity is always the driving force, however I guess my question would be, does it matter where the CC is pulled from? Example : I have a soap note.. it starts with no CC stated, the Subjective is something as;; The patient did well overnight. she has no new complaints. Goes on to give the objective and impression, which includes diag. and plan of treatment. I am being told to disregard the Subjective/ history and use the Objective and MDM to determine level. Per the objective and impression, it shows need for the hospital visit. Is this correct or should it clearly state in the Subjective or list the CC? We had been told in the past to make these unbillable as the CC was not clearly stated. However, I am being told that is not true??

Thanks for any help.. hope I am not being confusing.
 
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Every E/M needs Chief Complaint

Every E/M note needs a Chief Complaint.

Can't get any more clear than that.
Tell you hospitalists that they must list a CC. It can be as simple as CC: F/U admit for xxx (whatever admission reason was).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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