Care Plan at risk for Pressure Ulcers
Care Plan at risk for Pressure Ulcers
Care Plan at risk for Pressure Ulcers
Medicare Part B 2008 HCPCS and modifier annual update chart
Medicare Part B 2008 HCPCS and modifier annual update chart by Lori-Lynne Webb, CPC, CCS-P, CCP, independent coding consultant located in Melba, ID.
Medicare Part B 2008 HCPCS and modifier annual update chart by Lori-Lynne Webb, CPC, CCS-P, CCP, independent coding consultant located in Melba, ID.
Sample policy on standardizing E/M audits
Sample policy on standardizing E/M audits
Sample policy on standardizing E/M audits
Clinical Documentation Request
The form is used to measure a patient's degree of malnutrition.
The form is used to measure a patient's degree of malnutrition.
Blue card: Bacteremia sepsis
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Blue chart designed to help clinical documentation of Bacteremia sepsis. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
POA query form
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a Present on Admission (POA) query form designed to help clinical documentation improvement specialists identify whether an associated condition was present at the time of the order for an inpatient admission. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at http://www.cdiassociation.com/
Heart failure chart
HCPro's Association of Clinical Documentation Improvement Specialists (ACDIS) present a heart failure chart designed to help clinical documentation improvement specialists identify signs and symptoms of heart failure in the medical record. If you aren't an ACDIS member but would like to become one, or if you would like to learn more about ACDIS visit the ACDIS Web site at www.cdiassociation.com
Fifth digit classification table
A fifth lymphatic and hematopoietic tissue category code digit denotes a specific location where the lymphoma occurs. For example, lymphoma can occur in any one of the following locations on the body:
A fifth lymphatic and hematopoietic tissue category code digit denotes a specific location where the lymphoma occurs. For example, lymphoma can occur in any one of the following locations on the body:
Sample coding career ladder
When managers propose coder compensation levels to an organization's human resource department, they typically take into account both credentials and experience. For this reason, most HIM departments implement a coding career ladder that outlines objective and measurable criteria for advancement. The criteria must also define proficiency and can be tied to production expectations developed for the department. The following is one example of a coding career ladder. Consider implementing a similar system in your hospital if you don't already have one in place.
When managers propose coder compensation levels to an organization's human resource department, they typically take into account both credentials and experience. For this reason, most HIM departments implement a coding career ladder that outlines objective and measurable criteria for advancement. The criteria must also define proficiency and can be tied to production expectations developed for the department. The following is one example of a coding career ladder. Consider implementing a similar system in your hospital if you don't already have one in place.
Acute respiratory failure documentation prompter
Use this acute respiratory failure documentation prompter to help prompt physicians to document language that will affect severity-adjusted DRGs.
Use this acute respiratory failure documentation prompter to help prompt physicians to document language that will affect severity-adjusted DRGs.
Cardiovascular prompt card
Use this card to help prompt physician documentation for various cardiovascular conditions.
Use this card to help prompt physician documentation for various cardiovascular conditions.
Cardiac CCs
Use this prompter to help capture cardiac CCs.
Use this prompter to help capture cardiac CCs.
Discharge summary/discharge order form
Use this nifty form to track discharges, final diagnoses, and more. Source: North Kansas City (MO) Hospital. Reprinted with permission.
Use this nifty form to track discharges, final diagnoses, and more. Source: North Kansas City (MO) Hospital. Reprinted with permission.
Record review for H&Ps
Use this chart to ensure that critical elements appear on your history and physical forms. Source: Adapted from: Ongoing Records Review, Third Edition: A Guide to JCAHO Compliance and Best Practices, Coyright 2003, HCPro, Inc.
Use this chart to ensure that critical elements appear on your history and physical forms. Source: Adapted from: Ongoing Records Review, Third Edition: A Guide to JCAHO Compliance and Best Practices, Coyright 2003, HCPro, Inc.
Nephrology Attending Evaluation
Use this nephrology attending evaluation to track patients' condition. Source: Oregon Health & Science University, Portland. Reprinted with permission.
Use this nephrology attending evaluation to track patients' condition. Source: Oregon Health & Science University, Portland. Reprinted with permission.
Signature identification form
Use this form to help clarify physician signatures in the medical record. Source: Medical College of Ohio Hospitals. Reprinted with permission.
Use this form to help clarify physician signatures in the medical record. Source: Medical College of Ohio Hospitals. Reprinted with permission.
Query tracking sheet
Use this form to track queries as well as post-query payments. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Use this form to track queries as well as post-query payments. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Respiratory failure clarification tool
Use this tool to clarify respiratory failure and query physicians for documentation improvement. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-1047.html
Use this tool to clarify respiratory failure and query physicians for documentation improvement. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-1047.html
Unapproved abbreviations review tool
Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations. Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Disseminate this list to your coding staff so that they may track physician usage of unapproved abbreviations. Source: Ongoing Records Review, Fifth Edition: A Guide to The Joint Comission Compliance and Best Practices, reprinted with permission. For more information visit: http://www.hcmarketplace.com/prod-5043.html.
Documentation content/quality deficiency form
Use this form to track documentation and quality deficiencies. Source: Adapted from: Seven Steps to HIM Compliance, copyright 1998 HCPro, Inc.
Use this form to track documentation and quality deficiencies. Source: Adapted from: Seven Steps to HIM Compliance, copyright 1998 HCPro, Inc.
Facility E/M guidelines based on a point system
These facility E/M guidelines use a point system to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
These facility E/M guidelines use a point system to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
Facility E/M guidelines based on staff interventions
These facility E/M guidelines use staff intervention to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
These facility E/M guidelines use staff intervention to determine each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
Facility E/M guidelines based on staff time
This set of facility E/M guidelines uses time as a determining factor for each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
This set of facility E/M guidelines uses time as a determining factor for each level of care. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
General Progress Note Template
Use this template for a general progress note. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Use this template for a general progress note. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Observation services guidelines
These observation services guidelines define observation, explain average lengths of stay, outline what observation excludes, explain necessary documentation, and discuss medical neccesity. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
These observation services guidelines define observation, explain average lengths of stay, outline what observation excludes, explain necessary documentation, and discuss medical neccesity. Source: Guide to Outpatient Clinical Documentation Improvement: The first step in Revenuse Cycle Management, reprinted with permission. For More information visit: http://www.hcmarketplace.com/prod-1740.html
Metric template
Use this sample metric template for RVUs, uncollectable AVRs, and registration processes. Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission For more information visit: http://www.hcmarketplace.com/prod-4003.html
Use this sample metric template for RVUs, uncollectable AVRs, and registration processes. Source: Revenue Cycle Management: A Best Practices Toolkit, reprinted with permission For more information visit: http://www.hcmarketplace.com/prod-4003.html
Pneumonia query form
Use this sample pneumonia query form to ensure accurate data reporting for your facility or practice. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Use this sample pneumonia query form to ensure accurate data reporting for your facility or practice. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Cardiology doc pocket tool
This pocket guide for cardiology physicians includes common cardiology DRGs, common cormorbidities, and common conditions of catheterization patients. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
This pocket guide for cardiology physicians includes common cardiology DRGs, common cormorbidities, and common conditions of catheterization patients. Source: Guide to Inpatient Clinical Documentation Improvement Strategies to Ensure Compliance and Correct Reimbursement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-1047.html
Denial appeal letter
Use this sample letter when appealing denials at your facility. Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-3659.html
Use this sample letter when appealing denials at your facility. Source: Denial Management: Key Tools and Strategies for Prevention and Improvement, reprinted with permission. For more information visit http://www.hcmarketplace.com/prod-3659.html
