Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.
Physician documentation drives quality measures, but physicians often don't understand how the quality of their documenation relates to their quality of care.
In order to identify patients with a CC or MCC, coders need to know when to report additional diagnoses. William E. Haik, MD, FCCP, CDIP, and Jennifer E. Avery, CCS, CPC-H, CPC, CPC-I, discuss when to report a secondary diagnosis.
Q: I’ve heard that queries differ between critical access and short-term acute care hospital settings. Is this true, and if so, where can I find more information?
Does the patient really have sepsis? Experts say coders often struggle with this question because physicians don't sufficiently document clinical indicators.
Coders and billers may not completely understand how to charge for inpatient supplies. One misconception is that the room rate incorporates all supplies used for every inpatient. Another misconception is that payers will not separately pay for inpatient supplies.
Coders remain highly accurate when reporting present-on-admission (POA) indicators, but they need to maintain that accuracy. The OIG reiterates the importance of POA reporting in terms of monitoring hospital quality of care and the role that such reporting plays in CMS’ effort to align payment incentives with patient outcomes. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, and Nena Scott, MS, RHIA, CCS, CCS-P, offer tips to ensure complaint POA reporting.
Not feeling well? The problem could be in your small intestine. Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, reviews common conditions related to the small intestine.
In the third part of our series on Patient Safety Indicator 90, we focus on inclusions, exclusions, and coding and documentation vulnerabilities for PSI 7.
