E/M Weekly Tip: Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)

The physician must satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making, documentation in the medical record must include:

  • Documentation stating the stay for hospital treatment or observation care status involves eight hours but less than 24 hours
  • Documentation identifying the billing physician was present and personally performed the services
  • Documentation identifying the admission and discharge notes were written by the billing physician

For more information, please visit the Medicare Claims Processing Manual, 100-04, Chapter 12, Section 30.6.8 at CMS website (PDF, 1.3 MB).