Essential Documentation Pearls for the Hospitalist Provider

Presented by: Dr. John Stimler, DO, CPC, CHC, FACEP

Total Run Time:  27:47

The first step in ensuring maximum reimbursement for hospitalist services is in training providers in the nuances of proper medical record documentation. Given the inherent environment of the average hospital, it is easy to overlook the significance of proper completion of the medical record. Poor documentation precludes the ability to code a specific service and can result in down-coding of a visit to a lesser code. This webinar will educate hospitalist providers on proper chart documentation requirements intended to prevent documentation deficiencies and concomitant revenue loss.

Topics include:

  • Documentation of a comprehensive History and Exam
  • Time documentation
  • Critical Care case types
  • Problems list
  • Documentation of orders
  • Complications
  • Subsequent Visit documentation
  • MDM issues
  • Procedures
  • Counseling and coordination of care

    Hospitalist E/M Coding Explained - Part 1

    Presenter: John Stimler, DO, CPC, CHC

    Total Run Time:  40:43

    While thorough documentation is the baseline, the second step in ensuring maximum reimbursement for hospitalist services is in training providers and coders in the nuances of proper coding. The chosen MDM level is used in conjunction with the History and Exam levels to assist coders in determining the proper Evaluation and Management code for hospitalist services, but the requirements are detailed and specific. Hospitalist coding also requires a clear understanding and knowledge of inpatient E/M service codes, as well as critical care and observation service codes. Designed to address the most common hospitalist documentation and coding errors we have encountered as hospitalist coding auditors, this 2-part webinar will educate hospitalist providers on chart documentation and coding requirements for the different E/M levels with the intention of preventing revenue loss and compliance issues.

    Topics covered in Part 1 of this two-part hospitalist coding webinar series include:

    • Medical Decision Making (MDM)
    • Complexity tables
    • Patient status.

    Hospitalist E/M Coding Explained – Part 2

    Presenter: John Stimler, DO, CPC, CHC

    Total Run Time: 1:01:21

    While thorough documentation is the baseline, the second step in ensuring maximum reimbursement for hospitalist services is in training providers and coders in the nuances of proper coding. The chosen MDM level is used in conjunction with the History and Exam levels to assist coders in determining the proper Evaluation and Management code for hospitalist services, but the requirements are detailed and specific.  Hospitalist coding also requires a clear understanding and knowledge of inpatient E/M service codes, as well critical care and observation services codes. Designed to address the most common hospitalist documentation and coding errors we have encountered as hospitalist coding auditors, this 2-part webinar will educate hospitalist providers on chart documentation and coding requirements for the different E/M levels with the intention of preventing revenue loss and compliance issues.

     

    Topics covered in Part 2 of this two-part hospitalist coding webinar series include:

    • History and Exam requirements
    • Hospitalist E/M code choice summary
    • Documentation deficiency code results
    • Interval history
    • Discharge services
    • Observation care
    • Unit/floor time
    • Consultations