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What are the billing and coding guidelines for inpatient care?

Billing and Coding Guidelines . Inpatient . Acute, inpatient care is reimbursed under a diagnosis-related groups (DRGs) system. DRGs are classifications of diagnoses and procedures in which patients demonstrate similar resource consumption and length-of-stay patterns. A payment rate is set for each DRG and the hospital’s Medicare

Who determines the minimum required content of medical history and physicals?

It is the responsibility of the organized medical staff to determine the minimum required content of medical history and physical (H & P) examinations (see MS.03.01.01 EP 6).

Can a medical student conduct a medical history and physical (H&P)?

A medical student has no legal status as a provider of health care services, therefore, a medical History and Physical (H&P) conducted by a medical student would not fulfill the requirements.

When do I need to complete the H&P for ASC patients?

The H&P should specifically indicate that the patient is cleared for surgery in an ambulatory setting. The H&P must be completed and documented for each ASC patient no more than 30 calendar days prior to date the patient is scheduled for surgery in the ASC. In cases where the patient is scheduled for two surgeries in the ASC within a short period


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