Wiki Guidelines for coding hospital E/M services?

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trarut

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Hi, everyone.

I am stuck. My coding team has been auditing our office E/Ms for several years (our physicians do their own coding...I know, I know! :eek:). They now want us to branch out to include their hospital E/M services but none of us have done hospital E/Ms before to know what the documentation requirements are.

I've been researching this fruitlessly for awhile now. Does anyone have suggestions, links, resources, etc that would guide me in the right direction?

Tracy
 
Thanks for the link; I'll check it out right now. Unfortunately, our Medicare contractor is CGS and they provide little to no documentation for us.
 
The guidelines for E/M are the same in any setting, they just get applied a little differently depending on the code. This is defined by CPT.

On the inpatient side you only have 3 levels of service instead of 5. For subsequent care, history can be "interval" which means the requirements are the same except past family and social history is not necessary.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/MM7405.pdf


Hopefully the link will help you,

Laura, CPC, CPMA, CEMC
 
I think I'm making it worse...

I understand what informaton needs to be present. I think it's where that information is coming from that has me confused.

For example, a patient is admitted to observation for chemotherapy by the oncologist (our doc) and only sees the patient once, post-chemo & prior to discharge. The documentation in the hospital chart is a handwritten SOAP note. The oncologist also had his most recent office note included in the hospital chart.

Can I refer to the office note for elements of HPI that are missing from the handwritten note?

Is it even billable if the resident wrote it all out and the oncologist simply writes "as above" and signs it?

Tracy
 
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