Observation Documentation for Proper Coding, Billing and Reimbursement

Event Information
Product Format
Prerecorded Event
90 Minutes
Product Description

Use Observation Log in Reviewing Documentation and Appropriateness of Coding and Billing

The documentation requirement for observation services is enormous. Hence, it is imperative to know what observation is, how to distinguish it from inpatient admission, how physician should document to justify observation services, what should a physician document at discharge from observation to say the least.

In this information-packed session, Duane Abbey, Ph.D. will shed light on how an observation log can assist in justifying observation, should condition code 44 be used or not and how does the use of condition code 44 affect the documentation. He will discuss how nursing staff and other clinical staff should document to support coding and billing for observation. In this 90 minute audio session, you will get to know the importance of carefully tracking time and interrupted observation. Duane will talk about the kind of policies and procedures you need to effectively document, code and bill for observation.

In addition, you will learn why post-surgical observation is such an issue, whether observation followed by a procedure is a problem, how do auditors and private payers view observation services, and much more.

Objectives of the session:

  • Comprehend the concept of observation and associated services
  • Know how physicians should document to justify observation services
  • What all physicians should document when the patient is discharged from observation services
  • Your documentation must always support the coding and billing process
  • Know how observation differs from inpatient admissions
  • Insights on the medical decision making relative to the over 2-midnights rule
  • It is imperative to track hours of observation including intervening services
  • Know how an Observation Log can assist in reviewing documentation and appropriateness of coding and billing.
  • Make use of Condition Code 44 and the documentation requirements surrounding the use of Condition Code 44
  • Comprehend the use of standard observation protocols or care paths
  • Identify the documentation requirements that will satisfy auditor requirements
  • Know why Medicare is so concerned about post-surgery observation
  • Insights on how Medicare reimbursement is affected by a procedure performed after observation
  • Learn how private payers view and use observation services.

Agenda of the session:

  • Observation Services
      • Know the types and levels of services
      • Organization and provision of Observation Services
        • Dedicated units
        • Medical/surgical Floor Beds
      • Coding, Billing and Payment for Observation
      • Difference between Inpatient from Outpatient Observation
      • Physician supervision
  • Documentation requirement for Observation Services
      • Physician documentation know-how
        • Explaining Observation Services
        • Interim visits
        • Discharge from Observation summary
      • Insights on over 2-Midnights Rule
      • Use and advantages for an Observation Log
      • Nursing and clinical documentation requirement
      • Understand the Care Paths for Observation Services
        • Types of Care Paths
        • Documentation sufficiency
      • Physician Supervision
  • Ins and outs of Condition Code 44
      • Know when to use Condition Code 44
      • Utilization review involvement and documentation
      • Physician documentation requirements
      • Correcting mistakes
  • Insights on Auditing Observation Services
      • Know how to develop audit guidelines
      • Chart out the documentation package for Observation
      • Conducting mock audits
  • Discussion on Private Payer consideration for Observation
    • Changing inpatient to observation
    • Documenting requests from Private Payers to change Inpatient to Observation
  • Some special considerations
    • Insights on RAC Audits
    • Know the coordination with ER Services
    • Know the coordination with Inpatient admissions
  • Sources for Further Information

Ask a question in the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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, Chargemaster Coordinators, Financial Analysts, Compliance Personnel, and 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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