The CMS 1995 Documentation Guidelines for E&M Services begins with a list of general principles of medical record documentation. Number two on the list behind “the medical record should be complete and legible” is “the documentation of each patient encounter should include a reason for the encounter” (chief complaint). The Guidelines later go on to … Read more
Every hospitalist has had a patient leave AMA from the hospital at some point. What to bill depends on the service provided to the patient on the date of service that the patient left AMA. There are three main scenarios: When a hospitalist provides a face-to-face initial or subsequent visit service to a patient who … Read more
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