The 2021 documentation guidelines for INPATIENT services will be effective on January 1st, 2023, and we hope you’re ready!
What I want to address in this post relates to the middle column; Data. This has proven to be a problem in the office setting, which was our first rollout, and I can tell you, I think it’s going to be a beast of a problem in the inpatient space as well. In particular, I want to talk about Order and Review, which I do think is going to be an even bigger beast of a problem in the inpatient space.
Let’s first talk about Order. When we think about our orders in the inpatient space, specifically with hospitalists, we do have standing orders. A lot of times we find that these are not always in the documentation of the encounter because they are standing orders. Now, that’s going to be difficult when it comes to giving the hospitalist credit for placing those orders. This is something that you will have to figure out within your own organization. Maybe it’s going to come down to asking your hospitalist to make sure they refer to those orders in the documentation of their encounter, or actually including those standing orders in their note because they will not get credit for those orders if they are not housed somewhere or referred to in the documentation of their encounter.
(By the way, we have a nice little decision tree that we’ve provided for you to help you with when to give credit for those orders whether it’s inpatient, ED, or nursing facility…no matter where you are.) Click here to download the decision tree.
The next thing is Review. I think the review is going to be the bigger problem. In the inpatient space, we have that auto-import, just like we do in the office a lot of times, but in the inpatient space, it becomes a little bit bigger of a burden. We have all of these labs whether old, new, impartial, relevant, not relevant, and they get auto-imported into the EMR. Our providers often do refer to them; they review them with the patient, and they also review them themselves applicable to the note, and they want to get credit for them.
Before I continue, we need to discuss two different definitions according to AMA.
AMA incorporated a new definition in the 2021 March Technical Corrections, and it was a term they added called analyzed. The definition says:
“Analyzed is the process of using the data as part of the MDM.”
(So, we are actually using the data as part of the MDM.) It goes on to say:
“The data element itself may not be subject to analysis, but it is instead included in the thought process for diagnosis.”
(Meaning specifically when something is being analyzed, then of course we have our test and our review.)
You will also want to make sure to keep page 6 of the new 2023 revisions of 2021 guidelines flagged, especially when dealing with our inpatient providers. It says that
“Ordering a test is included in the category of the test results and the review of the test result is part of the encounter and not a subsequent encounter”.
So, for example, if the hospitalist orders a test and then a hospitalist on the next day reviews those results, even if it’s a different hospitalist, (remember, they are members at the same specialty), that hospitalist cannot get “credit” for reviewing those labs as part of the work of their encounter. We have to be very careful in how we’re analyzing the reviews inside the inpatient space. It’s going to get little a crazy. This is also going to carry forward into nursing facility spaces, which can get a little sketchy as well. Emergency rooms…patients are typically in and out, so that’s going to be a little bit easier. A better way to explain review would be the hospitalist ordered the labs and the cardiologist is coming in and reviewing those labs. That is a unique review of those labs and would certainly qualify as review.
You can watch my YouTube video on this topic -and we’re going to provide more of these blogs and videos to help you as you’re looking at how to apply the 2021 guidelines in these new types and place of service, so be sure to subscribe to our blog posts and the NAMAS YouTube channel!
If you do need help with training your providers, we’re always here. We’re providing all sorts of training right now for different providers in different settings, large health systems and small, so contact us at 877-418-5564 or email email@example.com if you need any help with that.