BC Advantage - 2019 Issue 1

Medical Necessity vs Documentation for Inpatient Services

Auditing the documentation of inpatient and observation E/M services can often be challenging. Many of the notes we are provided for review include so much information, that the note feels like a short novel instead of documentation for one date of service. This overdocumentation can make it difficult to see what is being treated by our provider. Some of this is caused by how inpatient EMRs are set up, but we (coders and auditors) are also responsible for providers thinking they must include so much information in every note. Over the years, we have drummed into their heads "If...

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