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...
In Coding
Dec 22nd, 2015
Delivering toys to children around the world in one day can take its toll. View Santa’s condition after last year’s voyage and how the professionals (elves?) at the North Pole Medical Clinic treated him. Santa gave his permission to share his chart. HIPAA regulations were followed in the creation of this graphic. Infographic: Santa’s Medical Chart ...