Wiki OBS to INPATIENT DOCUMENTATION

[PeaPod1]

Observation to Inpatient Status Documentation

--------------------------------------------------------------------------------

I am seeking information regarding documentation requirements when a patient moves from Observation status to Inpatient status.
Does the provider need to do a separate H&P when the status changes?
Thanks in advance for any assistance.

 

[OCD_coder]

Yes, think of it no different as an office visit as the documentation must stand alone and support the CPT code level of service. So the provider will need to do a separate H&P that meets all of the elements for the CPT reported.

To make it a bit easier to figure out what is the correct code, they are sort of point of service code sets.