Documentation and Coding

Documentation and Coding is for many physicians a distasteful aspect of the practice of medicine. As a result, documentation and coding is often viewed as a necessary evil, resulting in a reluctance to embrace and understand its importance. However, the impact of documentation and coding on a Hospitalist Provider and his/her group is multi-dimensional; affecting revenue/practice cash flow, the ability to ascertain the quality of care being rendered, possibly Hospitalist compensation (in wRVU-based comp models), and even exposing Hospitalists to unforeseen legal exposure.

The good news for Hospitalists is that the documentation requirements are fairly straightforward, the set of possible CPT Codes to be assigned for patient encounters are limited in number, and there are multiple resources which can provide solid guidance. And once a Hospitalist has invested time to learn this aspect of their practice of medicine, and developed relevant healthy habits; documentation and coding tends to become second-nature.

General documentation and coding considerations for Hospitalists:

• Daily documentation, and subsequent assignment of an appropriate CPT code, is extremely important
• CPT Codes are driven primarily by Disease Severity/Intensity and must be clearly delineated
• Specificity in documentation is essential
• Visit start and end times are important in many situations and should be documented
• Only one E/M CPT Code is allowable for each patient by the Group for any 24-hour day

For a free copy of our Hospitalist Coding Guide, please go to the Contact Us page, and submit your request.