Three Documentation & Coding Tips Many Hospitalists Miss

By  |  March 5, 2014 | 

by Barbara Pierce, CSS-P, ACS-EM

Good documentation facilitates good patient care. We all know that, but what about good documentation leads to proper coding and compliance?

If you’ve been under a rock since 1995, then you have an excuse for not knowing about the CMS/AMA Documentation Guidelines. Even though this guidance came to us almost twenty years ago, I still encounter hospitalists who are quite amazed when I educate them on requirements, such as what is considered a complete review of systems?

Everyone should work toward compliance in their coding efforts. Medicare is watching, and so are the other payers. Sometimes the line between compliance and revenue is blurred, but appropriate documentation and coding can often lead to revenue enhancement. While the focus of documentation and coding education is not to make more money, often that is one of the positive side effects. Everyone just wants to feel comfortable that they are doing the right thing.

Some physicians are tasked with assigning their own E/M (Evaluation and Management) levels, while others may have someone internally or externally providing that service. Either way, it is the physician’s responsibility to document appropriately, based on medical necessity, in order to capture the right codes. Here are a few documentation tips:

1.    On your first encounter with the patient, always document something from each of the following history areas: past, family, and social.

For example:
You could be admitting a 90-year-old female who is at high risk and medically complex, and if you forget to document her family history (although she most likely has outlived those family members who have come before her), you no longer have documented a Level 3 admission. In fact, you don’t even get a Level 2. The code selection would drop to a Level 1 admission, because that is the only admission code that allows for a non-comprehensive level of history.

2.    Remember that the risk and complexity of the patient is only part of the equation. Based on the medical decision making required, you can “back into” the amount of history and/or examination that needs to be documented. While you might think that you are entitled to the highest level of code for the patient, the medical decision making is only one-third of the process. Make sure your history and/or exam also qualify for that higher level , assuming there is medical necessity for that service.

3.    Don’t forget to code based on time. In the hospital setting, the time elements are met based on unit/floor time, and we all know you spend a great deal of time either counseling the patient or coordinating their care. Time becomes the controlling factory (therefore “trumping” the usual components of history, exam, and medical decision making) when the majority of the visit is counseling and/or coordination of care. I recommend you document three things when coding by time: Total time of the visit (in minutes), counseling/coordination of care time (in minutes) and a brief discussion of what took place.

More tips and advice on all aspects of E/M documentation and coding are being offered in the Society of Hospital Medicine’s remote online education series on documentation and coding, CODE-H (Coding Optimally by Documenting Effectively for Hospitalists). SHM has launched an updated series of webinars designed to help optimize your program’s revenue cycle performance and compliance, and to position you for success in meeting upcoming challenges such as ICD-10. I hope you will join us for this seven-session series.  The next webinar is scheduled for Thursday, March 20th.  You can learn more about it at


Barb PierceBarb Pierce is the President of Barb Pierce Coding Inc. She has extensive knowledge in the areas of coding and billing. Her strengths include an extensive knowledge of CPT and ICD-9 coding as it is applied in a medical practice. She is often asked to perform compliance audits and evaluations for practices and clinics of various specialties. She has worked with a number of hospitalist groups as well as speaking on coding and auditing at recent SHM coding events, including serving as faculty for SHM’s CODE-H online education series.

As a presenter for ongoing chart auditing workshops, she has become a national recognized speaker on the CMS/AMA Documentation Guidelines. Most recently, she helped develop the ACS-EM certification exam and study guide for the Board of Medical Specialty Coding, where she also serves as the E/M Advisor to the board.

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