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 care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. However, coding, billing and documenting observation services represent a very real challenge.

This webinar by expert speaker Duane C. Abbey, Ph.D., will discuss in detail about observation services and their corresponding documentation requirements. It will help you distinguish observation from inpatient admissions – in terms of the service rendered as well as learn about the compliance requirements.

As there are different documentation requirements for nurses and doctors – this session will help them both. Charge capture and proper billing issues will be discussed relative to the overall documentation process. Dr. Abbey will also address auditing standards so that both the documentation and documentation process can be assessed relative to external audits such as the RACs. In addition, special situations such as the use of Condition Code 44 and correction of errors will be discussed along with due consideration for the new NOTICE Act.

Training Objectives:

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

Session Highlights:

  • 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?

Session Agenda:

  • Observation Services
    • Types and Levels of Services
    • Organization and Provision of Observation Services
      • Dedicated Units
      • Medical/Surgical Floor Beds
    • Coding, Billing and Payment for Observation
    • Distinguishing Inpatient from Outpatient Observation
    • Physician Supervision
  • Documentation for Observation
    • Physician Documentation
      • Justifying Observation Services
      • Interim Visits
      • Discharge from Observation Summary
    • Over 2-Midnights Rule
    • Use and Advantages for an Observation Log
    • Nursing and Clinical Documentation
    • Care Paths for Observation Services
      • Types of Care Paths
      • Documentation Sufficiency
    • Physician Supervision
  • Condition Code 44
    • Criteria for Use of Condition Code 44
    • Utilization Review Involvement and Documentation
    • Physician Documentation Requirements
    • Correcting Mistakes
  • Auditing Observation Services
    • Developing Audit Guidelines
    • Preparing the Documentation Package for Observation
    • Conducting Mock Audits
  • Private Payer Consideration for Observation
    • Changing Inpatient to Observation
    • Documenting Requests From Private Payers to Change Inpatient to Observation
  • Special Considerations
    • RAC Audits
    • Coordination With ER Services
    • Coordination With Inpatient Admissions
    • NOTICE Act
  • Sources for Further Information

Who should attend?

  • Outpatient Nursing Staff
  • Medical/Surgical Nursing Staff
  • Nurse Managers
  • ED Nursing Staff
  • Utilization Review Personnel
  • Quality Assurance Personnel
  • Physicians
  • Non-Physician Practitioners
  • Coding Personnel
  • Billing and Claims transaction personnel
  • Chargemaster Coordinators
  • Financial Analysts
  • Compliance 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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