12 Things Hospitalists Need to Know About Billing and Coding
12 Things Hospitalists Need to Know About Billing and Coding
"The main thing that we see is missing documentation," says Angie Comfort, RHIT, CCS, a director at HIM Solutions. For instance, if a hospitalist documents congestive heart failure, it's important to indicate whether the condition is chronic or acute and systolic or diastolic.
In the case of a diabetic patient, the notes should specify the type of diabetes. Not doing so "could be a reimbursement-changer," Comfort says. In contrast, documenting such specifics could result in higher reimbursement, especially if a patient has complications from Type 1 diabetes.
5 Be Specific in Your Written Assessment of the Patient's Condition
"The main thing that we see is missing documentation," says Angie Comfort, RHIT, CCS, a director at HIM Solutions. For instance, if a hospitalist documents congestive heart failure, it's important to indicate whether the condition is chronic or acute and systolic or diastolic.
In the case of a diabetic patient, the notes should specify the type of diabetes. Not doing so "could be a reimbursement-changer," Comfort says. In contrast, documenting such specifics could result in higher reimbursement, especially if a patient has complications from Type 1 diabetes.
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