What are the documentation requirements for billing observation or inpatient hospital care services (including admission and discharge services)?

Answer 
Documentation requirements for billing observation or inpatient hospital care services (including admission and discharge services) should include:

  • Medical documentation of observation care or inpatient hospital care that was personally performed by or that confirms the presence of the billing provider in at least 8 hours, but less than 24 hours of the patient’s care
  • Dated and timed physician’s orders regarding the services the patient received,
    Nursing notes
  • Progress notes prepared by the physician while the patient was receiving care

Resource: CMS IOM 100-04, Medicare Claims Processing Manual, Chapter 12 (PDF, 1.05 MB), Section 30.6.8.C

 

 

Contact Railroad Medicare

Email Railroad Medicare

Contact a specific Railroad Medicare department

Provider Contact Center: 888-355-9165

IVR: 877-288-7600

TTY: 877-715-6397

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now