Essential Documentation Pearls for the Hospitalist Provider This webinar is AAPC-approved for 1.0 CEU and/or CDEO specialty credits provided you score a 70% or higher on the post test. Test takers should read all test instructions, and complete the Required Information fields at the top of the test. This test consists of 10 questions. Please select one best answer for each test question by clicking on the square next to the answer you have selected. This test is not timed; however, the test must be taken in one sitting. When all 10 questions have been answered, please click on the Submit Test button. Your score, as well as logic-reach reasoning for answers to any test questions that you missed, will be displayed immediately following completion and successful transmission of this test. For technical support for your Hospitalist Medicine Provider Documentation and Coding Webinar Library subscription please call or email: Cari Laplace Webinar Technical Support Administrator BSA Healthcare Phone: 1-561-434-4740 Email: claplace@bsanda.com NameCompany NameEmailA comprehensive History and Exam is required for all initial inpatient admissions and patients who are admitted from observation. A comprehensive History and a comprehensive Exam require which of the following: Four History of Present Illness (HPI) elements and Ten systems from Review of Systems (ROS) One item from each of Past, Family, Social History (PFSH) Eight Exam systems and a list of problems and the workup and treatment for each All the above.Discharge time must be documented as 30 minutes or less or greater than 30 minutes and includes all of the following with the exception of: The patient’s initial exam. The patient final exam. Instructions for continuing care. Chart summary, discharge records, prescriptions, and referral forms.True or false: Critical Care time should always be documented as a range of time lasting between 31 and 60 minutes. True FalseChart orders include the ancillary studies that are ordered by the physician to rule out various diagnoses as well as the therapeutic interventions that are ordered to treat the patient. Chart orders are best documented on the patient record in the following manner: All orders should be documented on the initial date of service record. Orders are best documented in the nursing notes. Orders are best documented directly under the problems they are intended to address but can also be documented in a separate area of the medical record that is dedicated to ancillary studies and therapeutic interventions. Either method is acceptable. Orders should ONLY be documented in a separate area of the medical record that is dedicated to ancillary studies and therapeutic interventions.To properly code a high complexity subsequent visit during which the Hospitalist did not perform an Exam, which of the following must be present on the medical record for that date of service: History and MDM. An interval history that includes four HPI elements and re-evaluation of the ROS and PFSH. An interval history that includes re-evaluation of the ROS and PFSH. A problems list with any orders, results, or complications.Medical Decision Making includes which of the following: Old record review, conversations with family, medical surrogates, or other providers, and visualization and interpretation of images (x-rays, CT, MRIs, ultrasounds, and EKGs) Completing a comprehensive History. Performing a comprehensive Exam. Documenting an interval history.Fill in the blank: With regards to counseling and coordination of care, hospitalists must document that greater than __% of total time was spent performing this activity: 30% 74% 50% 90%When a patient is admitted as an inpatient to the hospital from observation status, which of the following applies: On the date of inpatient admission to the hospital, inpatient admission codes should be used to code that date of service. The medical record for the date of service for inpatient admission of the patient from observation should include documentation of a comprehensive History and Exam. A discharge code should be used first followed by an initial admission code. Both A and BThe ability to bill for which of the following is lost when a discharge note is written prior to the day on which the patient is actually discharged: An observation care code. The subsequent care code. The discharge care code. A subsequent care code on that day as well as the actual discharge care code on the date of discharge.If transfer of the care of a patient occurs from a surgeon to a hospitalist after surgery, a hospitalist must document which of the following: A discharge note. Responsibility for assumption of management of the patient, and what is being managed and not just the reason for surgery. The reason for surgery. That the surgeon maintains responsibility for patient management following surgery.
