A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.