Melissa Posted Thu 19th of January, 2017 13:56:40 PM
If you bill an admit and discharge same day, whether it is out patient or observation do you need two separate reports? What needs to be included in the discharge?
SuperCoder Answered Fri 20th of January, 2017 02:04:35 AM
In accordance with CMS' Claims Processing Manual, when reporting an admit and discharge same day the documentation must include separate notes for admission and discharge work upnotes. In addition, the medical record must include:
1) Documentation meeting the E/M requirements for history, examination and medical decision making;
2) Documentation stating the stay for hospital treatment or observation care status involves 8 hours but less than 24 hours;
3) Documentation identifying the billing physician was present and personally performed the services; and
4) Documentation identifying that the admission and discharge notes were written by the billing physician.