Wiki Decision for hospitalization

[umhamza123@hotmail.com]

Hi,
When coding in the profee side H&P initial hospital visits and coding for the hospitalist doctor. If the provider does not list in his notes the decision for hospitalization can decision for hospitalization be counted as an element of risk in E/M leveling based on that it is listed in the face sheet and order tab of the EMR that he is the admitting provider? And if someone has a link to a reference on this issue?
Thank you so much

 

[thomas7331]

You can only use documentation that is signed by the provider as a source for code assignment. However, admission to inpatient status at a hospital requires a physician order which would have to be signed by the admitting provider. That order would be considered part of the record of the visit and would satisfy the requirement that the provider documented the decision to hospitalize the patient.