Background
The majority of clinical revenue to the Hospitalist Division comes from provider billing. Since most hospitalists receive a portion of their salary from collections and hospital subsidies, both are important to understand. This may seem painful and frustrating at first, but these concepts serve as the basis for many opportunities and negotiations.
Hospitalists have two major considerations in documentation for billing: provider and hospital services. While both use ICD codes, provider and hospital coders have different degrees, different office locations and different roles in the chart review and reimbursement process.
Key responsibilities for hospitalists in these two areas include:
Provider Billing: Assure complete ROS, accurate level of decision making, correct attending attestation, etc. in both H&P's and progress notes so that the UNM Medical Group (UNMMG) will be able to be reimbursed commensurate with provider efforts.
Hospital Billing: Assure accurate description of diagnoses for research, quality reporting (core measures, expected mortality) and establishing DRG's for hospital payments (UNMH HIM, Quality)
Tips and Guidance for Documentation
Sub-I Documentation Tips Coding
0 HM Billing Sheet Template.xlsx
Documentation Expectations
Electronic Progress Note Information and Tips
Copy and Paste Guidelines
Tips for Documenting Severity of Illness
List of Common MCCs and CCs to document
Problem List and Diagnosis Documentation (ICD10)
Definitions used in Coding, Billing and Documentation
Diagnoses of Interest
Individuals Involved in Documentation
Data Sources for Analysis of Coding and Billing (under construction)
Documentation Templates
Attending Attestations for Coding and Billing
Discharge Summary
Procedure Note Templates
Other Topics
Observation vs Admission
Draft Institution Wide Progress Note
Medical Director Role
Director of Documentation, Coding, and Billing
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