What does CMS advise if a provider fails to document a minimum of a detailed history and exam for the initial inpatient encounter?

When a provider fails to document the necessary components, including a detailed history and examination for an initial inpatient encounter, CMS guidelines indicate that the proper course of action is to utilize a subsequent hospital care code. This is because the documentation must support the level of service billed, and without the required elements in place for an initial visit, the visit does not meet the criteria needed for that coding level.

Subsequent hospital care codes are used for encounters that occur after the initial visit and involve follow-up care. This aligns with CMS standards, which aim to ensure that coding accurately reflects the services provided based on documented medical necessity. Coding the visit as a subsequent care code acknowledges the lack of documentation for an initial visit while allowing the provider to still receive reimbursement for the care rendered.

This situation underscores the importance of proper medical documentation, as it is critical not only for compliance but also for ensuring that providers are reimbursed accurately for their services.