Crystal's MCW Coder HubTags: compliance documentation inpatient
Core Documentation Elements
Initial Visit
| Element | Requirement |
|---|---|
| Chief Complaint | Patient’s reason for admission |
| HPI | History of present illness |
| ROS | Review of systems |
| PMH | Past medical history |
| Exam | Physical examination |
| Assessment | Diagnosis/impression |
| Plan | Treatment plan |
Subsequent Visits
| Element | Requirement |
|---|---|
| Interval History | Changes since last visit |
| Focused Exam | Relevant systems |
| Assessment | Current status |
| Plan | Ongoing treatment |
Cloned Documentation
Copy/paste documentation is a major audit trigger. Each note must reflect current patient status.
Time-Based Documentation
Time Documentation Example: “Total time spent: 45 minutes
- 20 min face-to-face with patient
- 15 min reviewing labs/imaging
- 10 min care coordination”
Signature Requirements
| Element | Requirement |
|---|---|
| Signature | Legible or electronic |
| Date | Date of service |
| Time | Required for critical care |
| Credentials | MD, DO, NP, PA |
Teaching Physician Attestation
Required for Residents
“I saw and evaluated the patient. I agree with the resident’s findings and plan.” [Signature/Date/Time]
Split/Shared Documentation
Provider A: 20 minutes - reviewed labs, discussed plan Provider B: 25 minutes - performed exam Total: 45 minutes Billing: Provider B (substantive portion)
Red Flags
- Missing signatures
- Undated notes
- Contradictory documentation
- Lack of progression
- Missing time logs for timed services
Daily Progress
Document daily for inpatient stays. Gaps in documentation raise medical necessity questions.
00 Inpatient ProFee Coding MOC Medical Necessity for Inpatient Audit Triggers Inpatient