Health Information Management

Avoid common hospitalist documentation errors

JustCoding News: Outpatient, October 17, 2012

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by Lois E. Mazza, CPC

Hospital medicine is a specialty that provides inpatient services for patients admitted to the hospital. The services provided by hospitalists allow primary care physicians (PCP) to concentrate on office visits and free the PCP from after-hours and pre-office-hours visits to the hospital to write orders and examine patients. These services are now often done by hospitalists.
Hospital medicine is no longer confined to primary care. Specialty medicine is also joining the field with hospitalists providing care for specialties including, but not limited to:
  • Neurology
  • Urology
  • Gastroenterology
As with any medical specialty, hospital medicine has unique demands and stressors. Services must be provided 24 hours a day, seven days a week. Groups must cover if providers need to take time off unexpectedly. Hospitalists often get interrupted for emergent situations as they attempt to dictate or write down documentation.
As well as providing inpatient services, hospitalists are often called on to consult in regards to and to follow medical problems that occur during hospitalization for surgery, psychiatric hospitalizations, and obstetrical patients.

Documentation challenges
Hospitalists need to document services rendered accurately and completely in accordance with rules and regulations from Medicare, other insurance carriers, and the facility where hospitalist provided services. Hospitalists also often must follow rules and stipulations from outside companies that manage the hospitalist group and/or provide the coding and billing.
Most hospitalist services are charged using codes for:
  • Evaluation and management (E/M) services (CPT® codes 99201–99215)
  • Hospital observation services (99218–99226)
  • Hospital inpatient service (codes 99221–99233)
  • Inpatient consultations, which are used less and less since Medicare decided not to reimburse these codes, however, some carriers do still recognize them (99251–99255)
  • Critical care (99291–99292)
  • Nursing facility services (99304–99318)
  • Prolonged services(99354–99359)
Some hospitalists also provide certain procedures such as:
  • Bronchoscopy
  • Tracheotomy tube replacement
  • Endotracheal intubation
  • Blood transfusion
  • Gastric intubation
  • CPR
  • Central line access
They need to document these services according to the rules and regulations regarding surgical procedures.
Like any specialty providers, some hospitalists are better informed than others when it comes to the rules, regulations, and guidelines regarding documentation of E/M services. Medicare provides specific guidelines for documenting E/M services. These guidelines are available at the CMS website.
Here are some common documentation errors made by hospitalists.
Incomplete documentation of the past, social, and family history
Medicare guidelines call for three key components of the record:
  • History
  • Examination
  • Medical decision-making
The history is further divided into three elements: history of present illness, review of systems, and past (medical), family, and social history (PFSH).
A patient is usually admitted to the hospital for a problem of high complexity. Medicare guidelines require documentation to support a charge for this level of service to include one specific item from each of the three history areas. The three history areas include:
  • Past (medical)
  • Family (medical)
  • Social
The documentation should include a summary of the patient’s past medical history, including illnesses, injuries, and surgeries, a notation of the patient’s family medical history, and notation of the patient’s social history. There should be at least one specific item for each history area.
If the hospitalist is unable to obtain a history, he or she should clearly note the reason For example: ‘Unable to obtain history due to patient being intubated’ or ‘unable to obtain history as patient has advanced dementia and no family members are present with the patient.’
While in my experience hospitalists virtually always document the past medical history and social history, they often omit the family history or use an invalid notation for documentation.
I have seen both histories listed as one (family and social history) but only the social history is actually documented. At other times, the hospitalist will state ‘non-contributory’ or ‘irrelevant to current illness.’
Medicare guidelines state: “A review of all three history areas is required for services that by their nature include a comprehensive assessment of the patient.” A high level code requires a comprehensive assessment.
Incomplete review of systems
The review of systems (ROS) is defined in the 1995 Medicare Guidelines as “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.”
Guidelines further define the ROS as ‘problem pertinent,’ ‘extended,’ and ‘complete’.  A ‘complete’ ROS is one in which the provider reviews at least 10 systems. In order to charge for a Level 3 inpatient admission, initial observation, or hospital consult, the provider must document a ‘complete’ ROS.
Medicare guidelines allow for systems with pertinent findings to be documented along with a statement attesting ‘all others reviewed and found negative’ or ‘a complete ROS was done, see HP I for details.’
The language of the documentation must clearly indicate the provider performed a ‘complete’ review in order for coders to report a Level 3 code.
Critical care services provided but not clearly documented
Many hospitalists often provide critical care to patients. Some hospitalists may not be aware that in order to charge for critical care, they must provide certain documentation. If a patient has a critical diagnosis, if critical care criteria is met, and the hospitalist spends at least 30 minutes providing critical care (aside from any procedures the hospitalist conducted for the critical patient), then the hospitalist may charge for critical care.
Critical care codes are time based, therefore, the hospitalist must attest or state that he or she provided critical care and note the total time spent providing critical care.
A statement to this effect would be acceptable: “I spent 30 minutes providing critical care for this patient.” Hospitalists need to note the total time because critical care codes are based on time and they can charge all of the time spent providing critical care in a 24-hour period.
No mention of discussion with other providers
When I audit records for hospitalists, I often see the patient had numerous consults during his or her stay but I fail to see any mention of the consults in the hospitalist’s documentation or a reference to any discussion with the consulting provider. Discussion with other providers results in credit for a higher level of service. Hospitalists should clearly note all discussions with consult-providing doctors, as well as other providers who care for the patient. Simply stating a specialty (such as cardiology, urology, neurology etic,) is ‘on board’ is invalid and will not result in credit for discussion with other providers.
Dates and times are missing
In this day, many physician services are recorded on an electronic medical record. An electronic record might be equipped to require providers to fill in  certain fields in order to complete and sign the record. For hand-written records, the writer is responsible for providing all necessary data for a complete record. One item I often see lacking in hand-written notes is the date and time the hospitalist provided the services.
I also often see that  one side of a progress note is timed and dated and contains patient identifiers, but when I turn the page over, the opposite side is missing one, some, or all of these items. This can be a problem  for records that are scanned or faxed to other locations.
Another error is putting the wrong information on the record, perhaps the previous day’s date or the wrong patient sticker, for example.
This type of error will hopefully become history once all documentation is recorded via an electronic record, although even advance technology carries the potential for error.
Time statement missing for discharge services
Discharge services are another complex subject for hospitalists. Codes for inpatient discharge services are time-based codes. One code denotes services taking 30 minutes or fewer (99238) and another for services that take greater than 30 minutes (99239).
Most discharge services for high or moderate level patients requires greater than 30 minutes to complete. The hospitalist must review the record and dictate a comprehensive note. In addition, the hospitalist must list the admission and discharge medications. The hospitalist must perform and document a face-to-face exam for Medicare patients in order to charge for discharge services.
The hospitalist must document and discuss discharge instructions with the patient and the patient’s family or other present caregivers. He or she must also discuss follow up plans snd answer any questions. All of these steps take a significant amount of time. It is important for the hospitalist to state ‘greater than 30 minutes spent providing discharge services for this patient’ if this was the case.
Hospitalist providers are human beings and as such cannot be expected to do anything perfectly 100% of the time. Given the nature and importance of patient documentation, perfection is a good goal for which all providers should strive.
As coders, auditors, clinical documentation specialists or anyone who is charged advising and education providers, we should continue to study and familiarize ourselves with guidelines, Medicare rules and regulations, and coding rules and guidelines. Provide education to hospitalists about acceptable documentation to help ensure the best possible outcome for the patient and to ensure the provider is credited with the actual work that has been done.
Editor’s note: Lois Mazza, CPC, is a documentation specialist for a medical management group that provides management services, as well as coding and billing services, for emergency departments, hospitalist medicine, and anesthesia groups in 46 states nationwide. She is certified through the AAPC since 2004. She has 16 years of experience working in the healthcare industry. Contact her at

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