Help overcome risks by understanding what protected health information is and how (not) to use it. Federal law limits how patients’ personal information may be used and disclosed. Here are the basics you should know to protect your practice when handling patients’ protected health information (PHI). Know What’s Protected  The HIPAA Privacy Rule protects patients’ ...
Failing to thoroughly document signs and symptoms, assessments, and treatments of chronic diseases creates a ripple effect of misfortune. First, all relevant codes are not captured; this leads to improper payment (not to mention, an injustice to the patient). The next thing you know, the claim fails a Risk Adjustment Data Validation (RADV) or Office ...
To assign an appropriate diagnosis related group (DRG), you must correctly identify present on admission (POA) indicators on all inpatient claims for services rendered in general acute care hospitals. This may be challenging if there are documentation deficiencies in the medical record. Here’s how to remedy those deficiencies. POA Review POA is defined as conditions ...
In Coding
Nov 14th, 2016
As with most things, when documenting in the medical record, it’s best to “get it right” the first time. And because human memory isn’t as reliable as we’d like to believe, it’s also best to document the patient encounter as it is rendered, or as shortly thereafter as possible. When amendments, corrections, or delayed entries ...
In Billing
Jul 11th, 2016
The Centers for Medicare & Medicaid Services (CMS) provides guidelines to assure that every patient’s health record contains quality documentation. Occasionally review the guidelines to keep them “fresh” in your mind. CMS general principles of medical record documentation for reporting of medical and surgical services for Medicare payment include (when applicable to the specific setting/encount...