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Documentation to Support Inpatient F/U?

  1. #1
    Question Documentation to Support Inpatient F/U?
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    Hello! I desperately hope someone can help! I code for an orthopaedic surgeons' office and frequently get inpatient consults to charge which I'm familiar with and I receive a copy of the dictation of. However, we have some docs who do their own coding and will submit to me a sheet with the initial inpatient visit and then anywhere from 1 to 3 additional codes for follow-up visits. When I asked for documentation of the follow-ups, the surgeons told me "it's in the patient's hospital chart; just go ahead and bill using the codes I gave you." This makes me very uneasy because I can't see anything in writing to support the code they are giving me (we are not EMR so I can't see anything on the hospital side). I can't find anything official in writing on the documentation requirements for follow-up visit billing on our end of it (the office). Does anyone know anything about this? Can I go ahead and just bill, trusting that whatever the surgeon documented in the patient's inpatient chart will suffice? I really don't know where to go with this and obviously don't want to miss any charges, but at the same time I don't want to bill fraudulently, of course. ANY INFO would be greatly appreciated!!!!

  2. #2
    I suggest looking at CMS internet only manual (Claims Processing Manual 100-04 in chapter 12, section 30.6). It outlines the expected documentation for physician billing, specifically, "Documentation should support the level of service reported." The E/M documentation guidelines may also be helpful.

    We have physicians who see patients at a variety of facilities that are not part of our EMR. In that case, I contact med records/HIM/coding department of that facility to ask for their process in releasing our physician's documentation to our coding dept. for a coding review. Most are helpful in this scenario. We also have, as part of a compliance plan, review of physician documentation in a facility. Perhaps, by spot checking several charts, you could either confirm that your docs are OK or need more education about required E/M components.

    Last edited by jek521; 10-25-2010 at 11:29 AM. Reason: editing punctuation

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