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Inpatient physician billing E/M

  1. #1
    Default Inpatient physician billing E/M
    Medical Coding Books
    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
    Location
    Kansas City, MO
    Posts
    434
    Default
    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,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  3. #3
    Default
    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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