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Wiki Inpatient Admission Documentation Requirements

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MWathen

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I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you :)
 
The codes 99221-99223 are not specifically 'hospital admission codes'. They are used to report the first time the provider sees the patient in an inpatient setting. Remember that these are used also in place of the previously covered consultation codes, which would not require a statement of admission either.

Additionally, there will always be an order in the patient's hospital chart that validates the inpatient or observation admission.

I know of no requirement to state that the patient is being admitted in order to assign the code. It's great documentation if you can get it, though.
 
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