What documentation is needed? The subject is inpatient billing by time documentation requirements. At work we are recently told that more than 50% counseling does not have to be documented, that it is inferred in the inpatient setting, that the provider only needs to note his total floor/unit time. My research shows that inpatient E/M still requires the the three time elements listed on the 1995 score sheet. This is an inpatient specialist not a hospitalist, in the year 2022. Thank you. Your input is much appreciated.
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