Wiki Inpatient physician billing E/M

[Tonyj]

I'm billing inpatient physician encounters. The physician forgot to include one crucial item on several inpatient encounters. CC: chief complaint. Can he include the CC after the patient has been discharged? If so, is there documentation via CMS etc that I can refer?

 

[LindaEV]

he can always amend his record to include it, even if pt is gone.

Check with your local Medicare carrier to be sure, but...
I was at a recent E/M seminar with my MAC which is WPS. She stated the CC is required of every E/M visit, but later stated on subsq inpatient visits, if there was no CC, the "entire record" could be submitted in it's place. I don't agree with this at all, but will certainly take advantage of the idea if needed.

However I still drill it into my docs that EVERY visit should have a CC!

 

[Tonyj]

Thanks for your input. The staff feels the same as you about CC on every encounter but I'll have to verify w/medicare about the addendum.