As CMS and third-party payers have looked for ways to treat patients in the outpatient setting and reduce inpatient volumes, CMS has used the 2-midnight rule, in addition to other methods, to treat patients as outpatients or in observation whenever possible.
Whether it is the CPT Manual or Chapter 12 of the Medicare Claims Processing Manual, the definition of a “new patient” is the same for physicians and nonphysician practitioners billing. But that doesn't mean coding and billing for E/M services is clear cut.
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of the revenue cycle.
When CMS introduced Hierarchical Condition Categories (HCC) with risk-adjusted scores, Ochsner Health System began efforts to educate providers and improve documentation across its many facilities.
Ochsner Clinic Foundation began its ambulatory clinical documentation excellence journey in 2004, when Medicare implemented its Hierarchical Condition Categories (HCC). Since HCCs affect patients’ Risk Adjustment Factor scores, and ultimately reimbursement for the care required to treat sicker patients, Ochsner needed to determine the best way to ensure annual HCC capture for all patients across its vast system.
There is an extensive list of coverage requirements that must be met to furnish outpatient services to Medicare beneficiaries. Hospitals may find that certain coverage requirements for therapeutic and diagnostic service are more difficult to meet than others, especially in off-campus provider-based departments.
