Code your inpatient visits with confidence
Hospital Coding is a E&M coding app developed to help you accurately code for common hospital based services like admissions, follow up visits, hospital discharges, and critical care services. This E&M coding reference is ready for the 21st century as an iOS app instead of a paper card. Select the level of service with confidence with Hospital Coding.
Included inpatient E&M services
- New Inpatient Evaluation (9922x codes)
- Inpatient Follow Up Visits (9923x codes)
- Observation Codes
- Discharge Visits
- Critical care services (New in v2.0)
How much does Hospital Coding Cost?Our hospital medical coding app is free and does not contain any ads.
What are E&M Services?E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new inpatient visit – level 2’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA. Not all medical services are covered under the E&M Documentation Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
How can I use this E&M Coding App to improve medical billing?Using this E&M Coding app will give you the confidence to bill at the highest level that is appropriate for the medical service you provided. This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk. Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010]. Inpatient coding is likely just as problematic, but no studies have been published to show the error rates for inpatient coding.
The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.Documentation Components from the 1997 Guidelines:
What needs to be documented for E&M services?
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality