E/M Coding: Break These 5 Bad Hospital Coding Habits

Why This Topic Matters

Subsequent hospital care coding patterns can affect compliance, audit risk, and reimbursement. Understanding documentation expectations helps practices support the level of service reported and identify possible undercoding trends.

Article Sections

1. Improving Subsequent Hospital Care Coding

   Introduces the topic of subsequent hospital care documentation and explains why repetitive low-level reporting can be a concern. Sets up the article’s focus on better coding habits and compliance awareness.

2. Step 1: Learn the Coding Levels

   Reviews the general levels used for subsequent hospital care and the importance of understanding service intensity. Also addresses how code levels can vary during a hospital stay.

3. Step 2: Warn Doctors of ‘Playing It Safe’ Dangers

   Discusses concerns that can arise when a practice repeatedly reports the same low-level service. Covers the potential for payer attention and the importance of avoiding patterns that may suggest incomplete documentation.

4. Step 3: Focus on MDM

   Explains the role of documentation components in subsequent hospital visits, with emphasis on medical decision making. Describes how the different documentation elements relate to code selection at a broad level.

5. Step 4: Add Your Documentation

   Highlights the kinds of patient observations and clinical details that may support hospital care documentation. Focuses on broad documentation themes and the types of information clinicians should capture.

6. Step 5: Review Charts to Identify Problems

   Describes the value of chart review for spotting repetitive coding patterns and possible undercoding. Also notes the broader financial and compliance implications of reviewing claims trends.

7. Bottom line

   Summarizes the importance of coding according to the documentation and maintaining day-to-day diagnostic specificity. Reinforces the article’s general message about accurate reporting in the hospital setting.