Why doesn't the physician know whether the patient is inpatient vs observation? Is it a consultation?
If you are the admitting service, you SHOULD know how you admitted the patient. Nevertheless, I have seen cases where the hospital admitted them as inpatient vs observation (and vice versa). I go to the original admission orders of the physician to clarify and, if necessary, get the hospital to change the status.
It sounds has if you have access to the hospital records, so I'd start with the admitting physician (if it's not MY physician) to determine if I should be using inpatient or outpatient codes.
If you have an understanding with your physicians that you will change the code to appropriate inpatient vs outpatient codes, then, yes, go ahead and do so. But in the absence of such an understanding (and clearly written protocol), you'll need to send the info back to the physician to be re-coded for the appropriate status.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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