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Inpatient Coding with Electronic Medical Records

  1. #1
    Smile Inpatient Coding with Electronic Medical Records
    Medical Coding Books
    I am hoping to get some feedback on a question that is haunting me. We have an electronic medical records system. Our physicians complete inpatient consultations followed by subsequent inpatient hospital care. The question I have is: Since this is a shared medical record and the physician states their Chief Complaint in their consultation and adds it to the patient's problem list for their admission, is it necessary to restate the chief complaint/ reason for visit in every subsequent hospital visit?

  2. #2
    This is an excellent question and I am hoping someone has a definitive answer.

    My opinion is yes, they still need a chief complaint on each visit. Generally this can be pulled from the history piece of the note though, and doesn't need to be a separate entry in the note. I don't currently have any providers utilizing EMR on the inpatient side, although it is available to them, so I am interested in how others are handling this issue as well.


    Laura, CPC

  3. #3
    For subsequent visits, document only an interval history. Payers assume that none of the patient's past medical, family or social history has changed since admission. They also assume that if anything has changed, you will update that.

  4. #4
    Thank you for the input. I would agree an interval history would be sufficient if done correctly. This is where it gets complicated for me. When a patient is admitted to the hospital, often there are multiple diagnoses/issues. When a physician doesn't state why they are following a patient and says something like "following up after CT. CT indicates impingement. Plan for OR in am." There is absolutely no indication of site,diagnosis, etc... My feeling is I cannot bill in this situation, though the diagnosis may be on the problem list it is never stated anywhere in the note. What do you think in this scenario.

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