Annie Posted Mon 13th of October, 2014 10:34:29 AM
If a patient is admitted to the hospital for Observation for instance 9/11/114 and provider is consulted to see the patient. The provider sees the patient and on 9/11/14 and writes progress note stating he saw patient but on transcribed note it has date of consultation 9/11/14 but dication date states 9/12/14 and patient was admitted to inpatient on 9/12/14. Do my charge date need to reflex 9/11/14 as obervation status even if transcribed notes states inpatient with date of service 9/11/14.
SuperCoder Answered Mon 13th of October, 2014 15:08:12 PM
Thanks for your question. Your dictation date my differ depending on when the note was dictated. If the documentation states that the date of service is 9/11/14 and that is the actual date that the provider saw the patient, 9/11/14 is the appropriate billing date. Now as for the question of inpatient versus observation, there are some instances where care management will change the status after the patient has already been seen. Check to be certain of the status for 9/11/14 before billing the visit. If the patient was truly in observation status on 9/11/14, you would need to bill an initial observation code. If your patient should have been admitted as inpatient on 9/11/14 you should bill the appropriate initial inpatient code. Hope this helps!