Initial Observation Care/Initial Hospital Care

[iluvicd9]

I am having problems with my docs choosing the correct E/M code when they see a patient in the hospital whether it be for outpatient observation or inpatient. Any advice?

We have a form that they can choose what level. But this has really created a problem. I need help!!

 

[FTessaBartels]

Education and form design

Sandy,

Does your form only have the codes on it, or do you have clear descriptions?

For example ... Have one "box" that's labeled: Admit for Observation
with the 99218, 99219 and 99220 codes underneath. Have a separate box labeled: Hospital Inpatient Admission with the 99221, 99222, 99223 codes underneath.

In cases like this education of the physician is key. And repetition of the message will be needed.

Is there one physician who seems to be the "coding guru" in your group? Maybe if you can spend some time with that doctor redesigning your form to make it easier and more clear that will help. You could also enlist this doctor's help in conveying the changes and message about correct coding to the rest of the providers.

Hope that helped.

F Tessa Bartels, CPC, CEMC

 

[iluvicd9]

Thank you for your suggestions. I have not been at this office quite a year yet and we need to work smarter not harder. I need to tweak our process and the physicians definitely need education. I think the problem could be getting past my supervisor to get the information to the administrator and physicians. We need organization and structure for our billing, which I must say is still in the dinosaur ages. Believe it or not we still file on the HCFA 1500 and do not have EMR.