(With (OPPS) Outpatient Observation & the 2-Midnight Rule - the Necessities)


By Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT    

Book Price:
1-10- $59.95/book

11-24 - $59.95/book

25 and more - $49.95/book

Shipping and Handling: $2.50 each

(Over 10 books, shipping and handling: free)

Why this handbook is written by a physician for physicians:
Inpatient (MS-DRG) documentation can be significantly different from Evaluation & Management (E&M) documentation. Physicians document acute care diagnosis, treatments, patient status & progress in the hospital setting. Coders only take the documented diagnoses and convert them to 7 digit codes (International Classification of Disease-10 [ICD-10]) that are submitted for data processing / reimbursement for services rendered. The 7 digit codes have to correlate to explicitly documented words within the medical record – and be present ‘verbatim’ when the medical record is reviewed by Auditors. Period. (Therefore a lab result is not a diagnosis.) Repeat: Physicians document, Coders code.

This pocket manual is meant to give you the most up to date Documentation Hints that will help you to communicate the quality of care being provided to your patients. It can help you to document the complete severity-of-illness, justify the utilization of resources, and demonstrate medical necessity to 3rd party payers. This can/will correlate to better reimbursements and fewer denials – in both the inpatient and outpatient settings.

Let us hear from you if there are any areas that you would like addressed in future editions. As you know the rules are modified at least every year. Our goal is to provide up to date information that is relevant, and usable, day-to –day in the communications of our practice of medicine.

Phone (Toll-free): (866) 227- 4407






Essentials of Observation: The Basics



By Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT and Nicole D. Harper, PhD, MBA, RHIA, CCS-P, CI-CDI

Book Price: $119.00

Get actionable answers to your toughest questions:

What is an observation patient? How do you establish medical necessity for observation care? Which physician documentation do you need? Do these questions sound familiar? We listened, and we created this easy-to-follow reference tool to help clarify the basics of observation services. There’s no need to struggle with your questions any longer, thanks to the clear, concise and actionable answers presented in this one-of-a-kind book. Our authors, Betty Bibbins, MD, and Nicole Harper, Ph.D., will guide you through a full range of issues, providing confidence that you’ve appropriately identified patients who are eligible for observation status, that you can support your charges for observation care and that you’ll be fully and correctly reimbursed for services rendered. Highlights:

  • Getting a firm grasp on the basics, including observation status defined, medical necessity requirements and the critical role of physician documentation
  • Shedding a bright light on two particularly confusing “gray” areas in the regulations: two-midnight rule and use of Condition Code 44
  • Conditions of participation — understanding the standards you must meet to enroll and maintain participation in Medicare and Medicaid programs
  • Crucial aspects of utilization review, from creating a functional UR committee to ensuring solid clinical documentation
  • Physician advisor’s evolving role within the acute-care setting: as a peer-to-peer liaison, on the UR committee, collaborating with case managers and more
  • ICD-10 coding primer — key differences between ICD-9 and ICD-10 codes and the more stringent physician documentation requirements under ICD-10
  • Case examples based on actual medical records, as well as diagrams, tables and tips, to reinforce critical points and to serve as at-a-glance reminders


Essentials of Observation: the Basics