Wiki Inpatient Documentation

[szrogers]

I am new to inpatient coding and I need to know if anyone can tell me what is the required documentation on the medical records, like the progress notes, to be able to bill the charge; can the doctor just sign his name to what a resident has written or does it need some other wording? HELP!

 

[kevbshields]

The facility should have specific guidelines for Resident supervision.

In addition, it would be advisable to search the CMS website for Resident supervision rules, as specified for CMS patients. Your facility may have guidelines that differ, and should be very clearly stated.

There are specific requirements for a Resident service to be "billable," so be sure you're accessing or requesting those from your employer.

Hope this helps & good luck.

 

[szrogers]

Thank you so much for the reply, that definitely is going to send me to in the right direction!