Tip #1: Recent reviews have revealed that RNs are copying forward the physician’s previous visit documentation including the exam and plan. Updates to the previous documentation may or may not be made. An external auditor is likely not to give credit for documentation brought over by an RN.
Tip # 2: NEVER share your ID and password.
Tip # 3: How to bill an inpatient charge:
1. Log in to your usual department and access the Patient List;
2. Open the patient chart and select the “CHARGES” activity tab;
3. Choose the category of service provided and then select the CPT code; and, then
4. A screen will pop up that allows you to select or add a diagnosis and a modifier.
Don’t forget to add modifier GC if you are linking your note to a resident or fellow.