Level of Care Setting: No Documentation Required

For Inpatient Levels of Care (LOC), you have the option to automatically populate the billable per-diem charge on the billing audit tool report without needing to add any billable evaluations or group sessions to the patient chart. The Require Documentation for Billable Day checkbox determines whether these daily charges populate automatically or only when documentation, such as group, evaluation, MAR, or vital, exists for that date.

Level of Care Configuration

You can use the no documentation required feature for any level of care with the LOC Type of Inpatient. Simply leave the Require documentation box unchecked. You can include hours, but it won't impact billing and will simply be visible on the billing audit tool report. 

When the Require Documentation for Billable Day box only applies to LOCs using per diem billing. When it is unchecked, changes are generated automatically for each authorized day as long as the patient is admitted, has an MRN, and is not marked absent. When the box is checked, documentation must be entered for a change to appear.

Setting	How Charges Generate
No Documentation Required	Automatically, each authorized day
Documentation Required	When daily documentation is entered
Attendance-based	When a group or evaluation is documented

Check out full instructions by billing integration: CollaborateMD | AveaOffice.

Generating No Documentation Required Charges

Let's review the process and requirements for generating per-diem charges without documentation.

1. First, the patient must be fully admitted, meaning that they have an admission date/time and an MR number.
2. Next, the patient must have insurance added to their account and be assigned to a UR Level of Care configured to not require documentation. Use this process to add the Utilization Plan for AveaOffice, and this process to add the Level of Care Concurrent Review for CMD.
3. The date range of the authorization determines when a per-diem charge is added to the Billing report. 
4. A charge will be added to the billing audit tool report at 12:00 AM in the location's time zone from the start date of the authorization until the end date of the authorization, except if:
   • The patient was marked as absent on the Attendance Tracker for the day,
   • The patient's level of care is changed to one requiring documentation, or
   • The patient is discharged.

When documentation is entered (such as MARs or vitals), it will appear in the expanded billing report only when no group or evaluation is documented for that date. If a group evaluation is documented, it will take priority and display instead, but the change still generates correctly.

Backdated Dates of Service: Any authorized dates of service added as part of a backdated authorization will automatically populate the billing audit tool report. For example: If the patient was admitted on 4/24 and the authorization was entered on 4/26, but covered dates of service from 4/24 to 5/2. After the authorization is entered, the report will automatically be populated with charge lines for dates of service 4/24-4/26.