Wiki Outside Physicians Billing for Private Practice.

[PatriciaWright]

To our knowledge the hospital can use the medical record as a running record. Does the running record apply to our providers when choosing and E&M and their documentation for billing purposes?

If it does apply or does not apply is there documentation to say either way?

 

[mitchellde]

In the medicare manual it is explained that an "encounter" for the facility inpatient is considered to admit thru discharge and the facility coder may use the entire stay. For physician or outpatient the "encounter" is each day the provider sees the patient. A medicar e Q& A I found says:
Medicare Comment #3: Every note must stand alone, i.e., the performed services must be documented at the outset. Delayed written explanations will be considered. They serve for clarification only and cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.

 

[PatriciaWright]

Thank you for the information. Do you know where in the Medicare Manual you found this?