Observation Documentation for Proper Coding, Billing and Reimbursement

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

Policies and Procedures to Effectively Document, Code & Bill for Observation Services

Observation services are one of the most challenging areas that hospitals face. In order to determine when a patient can be safely discharged, your staff needs a thorough understanding of the relevant coding and billing requirements for observations. Join expert speaker Duane Abbey, Ph.D., in this conference to learn how to distinguish observation services from inpatient admissions. He will also address best practices in physician, nursing and clinical documentation for proper reimbursements.

This presentation will also cover all aspects of charge capture and proper billing issues relative to the overall documentation process. Additionally, it will address auditing standards that both the documentation and documentation process can be assessed relative to external audits such as the RACs. Lastly, Duane will cover special situations such as the use of Condition Code 44 and correction of errors along with due consideration for the NOTICE Act.

The session will provide answers to the following questions

  • Just what is observation?
  • How is observation different from an inpatient admission?
  • How should a physician document to justify observation services?
  • What should a physician document at discharge from observation?
  • How can an observation log assist in justifying observation?
  • How should condition Code 44 be used or not?
  • How does the use of condition Code 44 affect the documentation?
  • How should nursing staff and other clinical staff document to support coding and billing for observation?
  • Why is it important to carefully track time and interrupted observation?
  • What kind of policies and procedures should be in place to effectively document, code and bill for observation?
  • Why is post-surgical observation such an issue?
  • Is observation followed by a procedure a problem?
  • How do auditors view observation services?
  • How do private payers view observation?
  • What is the Notice Act?

Training Objectives

  • Discuss the concept of observation and associated services
  • Review how physicians should document to justify observation services
  • Discuss what physicians should document at the time the patient is discharged from observation services
  • Review how documentation must support the coding and billing process
  • Understand how observation differs from inpatient admissions.
  • Briefly discuss the medical decision making relative to the over 2-midnights rule
  • Appreciate the need to track hours of observation including intervening services
  • Understand how an Observation Log can assist in reviewing documentation and appropriateness of coding and billing
  • Appreciate the use of Condition Code 44 and the documentation requirements surrounding the use of Condition Code 44
  • Identify the need to fastidiously address use of the MOON form
  • Understand the use of standard observation protocols or care paths
  • Learn the documentation requirements that will satisfy auditor requirements
  • Know why Medicare is so concerned about post-surgery observation
  • Realize how Medicare reimbursement is affected by a procedure performed after observation
  • Understand how private payers view and use observation services

Who should attend?

  • Outpatient Nursing Staff
  • Medical/Surgical Nursing Staff
  • Nurse Managers
  • ED Nursing Staff
  • Utilization Review Personnel
  • Quality Assurance Personnel
  • Quality Assurance Personnel
  • Physicians
  • Non-Physician Practitioners
  • Coding Personnel
  • Billing and Claims Transaction Personnel
  • Charge master Coordinators
  • Financial Analysts
  • Compliance Personnel
  • Other Interested Personnel

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
More Events By The Speaker

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