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Thread: Inpatient physician billing E/M

  1. #1
    Join Date
    Apr 2007

    Default Inpatient physician billing E/M

    AAPC: Back to School
    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?

  2. #2
    Join Date
    Apr 2007
    Kansas City, MO


    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!
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Join Date
    Apr 2007


    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.

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