Course 6: Billing & Disposition Flashcards
Disposition (3)
pt’s destination after leaving the ED…
- Discharged
- Admitted
- Transferred
Hospitalist
Physician that cares for a hospitalized patient
E&M Levels
set of criteria that determine how a physician can be paid for their services
Level 5
highest level of billing
down-coded
when a physician can only be reimbursed for a lower level of care due to inadequate documentaiton
Caveat Statement
- a disclaimer—»evaluation may be limited secondary to:
- respiratory distress
- unresponsiveness
- clinical condition
- dementia
- AMS
- limited cognitive ability
- Document “Unable to obtain a complete ___ due to ___” in each section independently:
- the HPI, ROS, Past History, and Physical Exam.
- Otherwise the chart will be down coded due to the missing information.
Quality Measure
a national standard among ED physicians that dictates the care and documntation requried for each diagnosis or complaint
DC’D
[what to document] (5)
- Discharged Home—»remember to document…
- Follow-Up—» told who to follow-up with (PCP, local clinic, specialist)
- Time period in which to follow up—» # days until pt follow-up
- specific conditions for return to the ED—» specfic sx that if expereinced the pt should return to ED
- Condition: “stable for discharge”—» documented on every chart being discharged “stable for DC”
- Time of disposition—» document the time of the discharge and of the re-evaluation
Hospitalized
[what to document] - (5)
- Admitted (usually to hospitalist/internist)
- admitting physician:
- time of consult w/admitting physician—»time stamp of when physician speaks w/the consulting dr (what was discussed and who agreed to admit the pt)
-
patient condition: clinical condition of pt —»provided by dr. as…
- Good,
- Fair,
- Serious,
- Critical
- Admission Locaiton: area of hospital (ICU, Tele, OR, etc)
- Admission Time: time of admission
Transferred
[what to document] (4)
Documenting an AMA Note
(7)
How to code Level 5 for the…
HPI
How to code Level 5 for the…
ROS
How to code Level 5 for the…
PMHx