Steps to Ensure Efficient Hospitalist Coding

by | Published on Mar 21, 2016 | Medical Coding

Hospitalist Coding
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Hospitalist coding needs to be accurate and efficient since it directly affects reimbursement for the integral services rendered by the hospitalist.

The hospitalist is an integral part of the modern healthcare system. This physician, who primarily focuses on the general medical care of patients who are hospitalized, serves as the point of contact for the patients and relatives with the hospital. In this regard, the hospitalist also performs non-medical tasks such as briefing, encouraging, and counseling patients as well as carrying out research on hospital medicine. Hospitalists can also exert a leadership role in hospital medicine.

Hospitalists Integral to Successful Functioning

In other words, hospitals need hospitalists to help them render efficient care and build goodwill in patients and their loved ones. They perform the very important task of functioning as the hospitalized patient’s primary care doctor and also ensuring that details of the patient’s diagnosis and treatment are conveyed to his/her primary care physician. As you realize, this would instill confidence in patients and their relatives even if their primary care doctor isn’t present.

However, hospitalists also need skills to ensure the reimbursement process works fine. And it all depends on medical billing and coding. They need to remember a few things when it comes to the all-important documentation based on which coding is done. The following points should help them ensure they are on the right track:

Documenting Patient and Family History during Initial Visit

The initial hospital visit must be documented thoroughly. This involves documenting the history of the patient, the physical assessment, and the medical decision making process. The history must contain:

  • Chief complaint of the patient
  • Review of the organ systems of the patient
  • Family history of the patient

Each of these histories is important since if one of them is left out – the family history of the patient is one of those commonly overlooked histories – the rendered service would be down-coded in spite of the comprehensiveness of the documentation involving the exam and the decision making.

To make the patient’s discharge process smoother, it helps if the hospitalist gets to know the social history of the patient by asking him/her. There could be social or family circumstances contributing to the hospitalization. Sometimes these circumstances could complicate the discharge process and require the assistance of a social worker.

Medicare State Rules and Organ System Documentation

Now this almost goes without saying, but hospitalists must get familiar with Medicare rules of the particular state where they practice. Procedures and rules vary between states. Medicare contractors in some states require healthcare providers to provide documentation of each of the organ systems reviewed individually. In some states though, it suffices to provide documentation of a system review with relevant positive or negative findings and the statement of all other negative systems.

The review will be credited by the auditors based on how many organ systems are documented. Missing a system review could bring a Level Three admission all the way down to a Level One, which would significantly affect the hospital financially.

Including Actual Diagnosis for Efficient Coding

Hospitalists must ensure there are no big loops in their documentation. The actual diagnosis must be included. Only then can coders assign the right code. This helps ensure the coders can avoid querying physicians to enquire about the diagnosis for assigning a code.

Conveying the Seriousness of the Patient’s Condition

In this regard, hospitalists also need to be specific in their documentation of the condition of the patient. When a hospitalist documents a condition, they must ensure that they specify if the condition is of an acute or chronic nature, or is systolic or diastolic. Failure to specify the nature or seriousness of the condition could reduce reimbursement.

Billing only for the Hospitalist’s Role in Treatment

Hospitalists should clearly indicate the particular aspect of the condition of the patient that they are involved in, if there are multiple healthcare professionals involved in the treatment of a hospitalized individual. This is apart from the involvement of specialists. It must be made sufficiently clear what the role of each clinician was, since multiple providers contribute to the inpatient documentation. The billed codes need to be supported by the respective documentation for each of the services. Hospitalists must only bill for the diagnosis code involving their specific treatment and not for what the specialist treats.

Documenting their Review of Reports and Scans

Hospitalists should not consider it unimportant to document what they’ve reviewed of the various reports, lab data, scans and tests. Hospitalists personally examining X-ray or MRI images could contribute to higher reimbursement, according to experts. While reviewing old records, providers must ensure that they include a synopsis of how the obtained information helped in the treatment plan.

Combining Billing for Patient Transfer within Hospital

Sometimes patients would need to be transferred. It could be from one hospital section to the rehabilitation unit. Each of the patient’s visits is covered by the exact same hospitalist practice in a single day. In this case it would be wiser to not bill for separate hospital codes, because the second claim eventually gets cancelled as denied service and both the visits occurred the same day. Combining both the services could result in a possibility of billing higher.

Hospitalist Signature Essential for Reimbursement

The signature of the hospitalist is important for reimbursement. Illegible signature could result in services being unpaid by Medicare and other insurance companies. Recording the time and date of the hospital visit is equally important since the providers wish to know the exact time the patient met the hospitalist.

As you can see, that’s quite a lot of things to remember. However these are vital to ensuring efficient hospitalist coding since effective reimbursement counts on it. Outsourcing medical coding for hospitalists can help contribute to efficient coding, higher reimbursement, and streamlined functioning.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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