E/M: Column 3 Hospitalization Consideration
Date Posted: Friday,
March 14, 2025
Many healthcare professionals face challenges when interpreting the AMA guidelines on high-risk consideration for hospitalization. The only documented reference to this guideline appears on page 7, where it states that a decision about hospitalization should include consideration of alternative levels of care.
This designation of high risk identifies patients whose conditions may require a more advanced level of care than what is available in their current setting. This nuance is vital because it encourages physicians to document beyond a binary decision of admission versus non-admission. Instead, the physician should document the risk to the patient if alternative levels of care are not part of the treatment plan.
Consider the following example to illustrate this point:
Office visit scenario: A patient is seen in a physician's office with dehydration and signs of illness. The physician evaluates the patient and determines that they should proceed to the emergency room. Many patients with the same complaint do not require the level of care available in the ED. Therefore, the physician must document the complexity of the presenting problem that yields this high-risk classification at that time. Furthermore, the physician should also document the risks that the patient faces if they do not follow through with the alternative level of care. Training physicians to record the risk of not following this directive helps them understand that this level of risk needs only apply in acute situations, not in cases where the patient is left untreated.
This underscores the importance of a thoughtful and individualized approach to documentation, where the focus is on matching the risk of management to the specific documented complexity of the patient.
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Source: Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN
Shannon DeConda is the Director of Coding and Reimbursement and a DoctorsManagement partner. She is also the founder and president of NAMAS (National Alliance of Medical Accreditation Specialists), an organization that provides education for medical documentation auditing, compliance, and exam preparation for the AAPC's national auditing credential CPMA (Certified Professional Medical Auditor).
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