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Tag Archives: Inpatient

Coding Inpatient and Observation Services in 2023

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AAPC leadership answers your questions about reporting and auditing hospital inpatient and observation services in 2023. Attendees at AAPC’s AUDITCON, Nov. 3-4, 2022, came loaded with questions about the coding and guideline changes for evaluation and management (E/M) services in CPT® 2023. The conference offered several sessions on the subject, including “Audit Approach for Hospital […]

The post Coding Inpatient and Observation Services in 2023 appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Inpatient Admission Documentation Requirements

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I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you :)

Medical Billing and Coding Forum

Inpatient Admission Documentation Requirements

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I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you :)

Medical Billing and Coding Forum

How to get hired as an Inpatient coder..any advice?

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Hello,

I am currently working as a coder for an orthopedic group..coding consults, surgeries etc.( 2 yrs exp. and CPC)
Is there any way to get hired as an Inpatient coder…even with such transferable skills, I’m having no luck..can any Inpatient coders please give me some advice?
Thanks so much

Medical Billing and Coding Forum

Dx rule in Inpatient setting pro fee

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Hello, I would greatly appreciate your expertise in the following scenario that leads to the general question ‘Do we code the condition as it still exists or a history of the condition when MD write Progress Notes during multiple subsequent visits and the surgery was already done on day #1?"
Example, A/P day 3 etc "Female with SAH (hemorrhage) on 3/10 due to Right PCoA aneurysm, s/post balloon-assisted coiling on 3/11. Vasospasm treated with IA Verapamil 3/15, 3/18. Stable neuro exam
– Vasospasm watch
– TCD today
-Plan for cerebral Ag Thursday
-Following"
Do we still code I60.31- aneurysm w/hemorrhage and Z98.890- post procedural state even though it’s been operated and no hemorrhage exists OR we code History of hemorrhage + Z98.890?
Thank you very much.

Medical Billing and Coding Forum

inpatient substance abuse treatment

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Hi, i bill for a hospital in NY that does inpatient substance abuse treatment ( detox and rehab), they also do medication maintenance once patient is discharged, and pain management for patients who have to use opiates to treat medical conditions. I have been searching for days on the correct way to bill these encounters. as in correct cpt codes, pos when admitted and during outpatient visits. For all inpatient we are using cpt codes 99221-9922 and 99231-99233 with pos 21 for all admitted detox and rehab patients. Then for the medication management we use 99201-99205 or 99211-99215 with pos 23? can anyone tell me where to find help at.

Medical Billing and Coding Forum

Remote device check while Inpatient for another illness

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I have a claim that was not paid by Medicare for a patients routinely scheduled remote 90 day device check (93297 and 93299). The patient was inpatient at one of our facilities at the same time (for another reason), by our Cardiologist billed a visit for that date too. A/R is stating that we cannot bill for the remote check since the patient was in the hospital. I don’t recall coming across this issue before…….any input/clarification/resources from my fellow Cardio coders would be appreciated.

Medical Billing and Coding Forum

Inpatient Consults/ICU Care /Postop within global period

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I am new to this ENT specialty. Several of our physicians do many surgeries and spend significant time doing follow-up in ICU or other post-op follow-up visits….Typically for complications of surgery (i.e. tonsillectomy bleed or CSF sinus leak), other than billing for the complications procedure, such as 42962 with a -78 modifier. Is anyone aware if there is a way to capture the followup inpatient visits, within the global period, especially critical care/ICU care. I have not been able to find any way to capture any charges aside from a procedure they perform, when in the global period. This is a new specialty for me. Thanks.

Medical Billing and Coding Forum

Inpatient coding guidelines

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I am working towards getting my cert in inpatient coding but do have a question when it comes to diagnosis coding. So if the patient came to the ER then was admitted as inpatient would I just code off the discharge summary or can I code from the discharge summary and the ER report? I just want to make sure I have that concept down.

Medical Billing and Coding Forum