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Documentation and Billing

Page history last edited by Kendall Rogers 3 years, 6 months ago


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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