Documentation is needed by an outpatient hospital to support billing the visit E/M?

valerie@valorizeconsulting.comvalerie@valorizeconsulting.com
in CODING & DOCUMENTATION
When a patient sees a physician or non-physician practitioner at an outpatient hospital visit, what documentation is needed in the medical record to support the facility visit charge.  I understand that the physician and non-physician practitioner note, alone, does not support the facility E/M visit charge, correct?

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  • valerie@valorizeconsulting.comvalerie@valorizeconsulting.com
    That is correct, there should be a separate document that captures the intake tasks of the nurse or medical assistant, such as interval history and vitals and the same document can capture the discharge tasks of the nurse or medical assistant such as arranging for tests or procedures, education, explaining prescriptions, etc.  While this information is often blended into the physician or non-physician note, it is not easy to audit to justify just the hospital employees' services separate from the physician or non-physician professional services. This is what should be documented to support the facility E/M visit charge.  Caution with some EHR systems that have to be programmed specifically to produce this as a separate document because they usually do not produce this without the hospital investing in the programming and insisting that it be done.
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