Wiki Hospital Visits

[medcode12]

Does every ones work place have an encounter form with documentation from the physician when he/she sees a patient in the hospital?

 

[cedwards]

I'm not sure exactly what you are asking. When our physicians see a patient in the hospital they complete an encounter form with the appropriate e/m code and dx code but that's it. We don't require the physician to bring back their documentation to the office in order to bill.

 

[FTessaBartels]

Yes

We do have an encounter form for the physician's use ... it's in the front of each patient's hospital chart.

However ... we're a hospital based practice (large academic medical center), and our coders have full access to hospital records. We don't rely on the physician completing the encounter form ... our inpatient abstractors read every chart, front to back, and abstract all charges (except the surgeries, which are done by a different group of coders directly from the op reports).

So, even if the physician completes the encounter form, the coder is using the actual documentation to determine the accurate level of E/M. If it differs from what the physician marked on the charge sheet, the coder sends the physician a note explaining why the actual code was different (could be higher, could be lower).

Cedwards - how do you audit those hospital visit E/M if you don't have documenation?

F Tessa Bartels, CPC, CPC-E/M