Wiki MDM High Risk - Decision for Hospitalization

[jmlarzzaapc]

We work with an ED where the ED providers do not have admitting privileges. However, they document the decision to admit patients to the hospitalist service within their ED notes and we give them credit for high risk for their decision for hospitalization. We also code for the hospitalist group, who places the admission orders and evaluates the patient to be admitted (they are not evaluating them in the ED, so it is not a consultation situation). The hospitalist providers want to receive credit for their decision for hospitalization by using only their orders to support a high risk. I am unable to find any resources from the CMS and/or AMA to support the high risk for the hospitalist orders only. Can anyone please provide this guidance? Thank you!!

 

[Cls1530]

Boy this is a tricky area. They are escalating care to the best of their ability. I would think it depends on the documentation. Which is really not what you asked. But if they can fully support the necessity and the severity, that would help the escalation of care.

 

[kdlberg]

They have to meet two out of three levels, and while decision to admit is a high risk management option, what's the presenting problem or problems? What data is being reviewed?

 

[amyjph]

It really depends. As stated above, tricky. Who actually made the decision? In your example, I would give it to the ED provider. I think you would have to do a case by case basis and look at the documentation and decide. If you took the hospitalist documentation and info, without knowing anything else, would it meet the level? Probably not. Look at the notes and documentation stand alone for the CPT being billed, that's what an auditor is going to do.
You still have to code it by the other boxes 2/3.
Maybe both would meet it if you look at the notes stand alone. Because, even without the 3rd box, the other two may get them there (COPA, data).