Q&A: Inpatient and Outpatient Bedside Procedures

Q: Is there a difference in the documentation requirements for bedside procedures when performed on an inpatient versus outpatient?

A: The documentation requirements for a bedside procedure do not change based on whether the procedure is performed on an inpatient or an outpatient. In both cases, the documentation must support the procedure provided, and there must be a physician or NPP order when hospital staff provide the procedure. Some procedures may be considered to be “included in the room rate” and therefore have never been reported separately, but regardless of whether the services are charged as part of the room rate or are charged separately, documentation is still required to support the service was provided.

For more information, see the Billing for Ancillary Bedside Procedures Training Handbook.

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