Inpatient Documentation Billing: Pearls and Pitfalls

We are pleased to offer this expert-led training module, Inpatient Documentation Billing: Pearls and Pitfalls, presented by Anne Perrin, MD, MPH; and Danica Smith, DO, as part of our continuing education series aligned with the University of Pittsburgh Department of Medicine’s 2025 Update in Internal Medicine (UIM): Practice Changing Advances. This self-paced session delivers timely, evidence-based insights to support clinical decision-making and enhance patient care.

Target Audience

Physician, Advanced Practice Provider, Nurse, Nurse Practitioner, Pharmacist, Physician Assistant, and Other Healthcare Professional.

Learning Objectives

Upon completion of this activity, participants should be able to:

  • Refine clinical documentation by improving diagnostic specificity, applying Present on Admission (POA) indicators, and utilizing MEAT (Monitor, Evaluate, Assess, Treat) criteria.
  • Identify opportunities to enhance documentation quality during transitions from observation to inpatient status.
  • Apply billing principles by documenting medical decision-making (MDM) vs. time-based services
  • Explain appropriate billing practices for prolonged services.
Course summary
Available credit: 
  • 0.75 AAPA Category I CME
  • 0.75 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 0.75 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 0.75 Attendance
Course opens: 
10/22/2025
Course expires: 
06/30/2026

Presenters:

Anne Perrin, MD, MPH
General Internal Medicine
Clinical Associate Professor of Medicine
Department of Medicine, University of Pittsburgh

Danica Smith, DO
Clinical Assistant Professor of Medicine
Section of Hospital Medicine
Co-Director, Academic Development
Co-Director, Hospitalist Certificate Program
Director, APP Development and Education
Division of General Internal Medicine
University of Pittsburgh

CONFLICT OF INTEREST DISCLOSURE

No members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships with any companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.


DISCLAIMER STATEMENT

The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses.

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In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician (CME)
The University of Pittsburgh designates this live activity for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity enables the participant to earn MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn ABIM MOC points equivalent to the amount of CME credits claimed for the activity.

Nursing (CNE)
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.75 contact hours.

Physician Assistant (AAPA)
The University of Pittsburgh has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.75 AAPA Category 1 CME credits. PAs should only claim credit commensurate with the extent of their participation.

Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.

Available Credit

  • 0.75 AAPA Category I CME
  • 0.75 AMA PRA Category 1 Credit™
    The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
  • 0.75 ANCC
    UPMC Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation
  • 0.75 Attendance
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