BC Advantage - 2019 Issue 5
Auditing Hospitalist Services
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Article Overview
This audit tip discusses common inpatient coding and documentation issues encountered with hospitalist services. It focuses on how timing and documentation affect admission billing, how split/shared circumstances can affect claims review, and how diagnosis coding should be evaluated in a post-operative inpatient stay. The article is intended for coders, auditors, compliance staff, and hospital-based revenue cycle teams who review hospitalist encounters and supporting records.
Why This Topic Matters
Hospitalist services often involve complex inpatient documentation, multiple providers, and date-sensitive billing scenarios. Understanding the audit risks described in the article can help reviewers assess whether the record supports the reported service and diagnosis selection.
Article Sections
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What is a hospitalist?
Introduces the hospitalist role in the inpatient setting and describes how hospital-based care teams may coordinate with other clinicians and support staff.
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Auditing admission services for hospitalists
Covers admission timing concerns, late-night inpatient admissions, and documentation review issues that can arise when multiple providers are involved.
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Auditing diagnosis coding for hospitalists
Discusses diagnosis assignment in an inpatient post-operative context and the documentation considerations that may affect principal diagnosis review.
What You Will Learn
- How hospitalist inpatient workflows can affect audit review
- Why date-of-service accuracy matters for admission records
- What documentation issues may arise when multiple providers participate in an inpatient admission
- How diagnosis selection can be evaluated in a post-operative hospitalist stay
- What general factors auditors review when assessing hospitalist documentation
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Hospital revenue cycle teams
- Inpatient documentation reviewers
Codes Discussed
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