Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
When HIM professionals at Driscoll Children's Hospital in Corpus Christi, Texas, looked into its success rate for physician response to coding queries, it knew it needed to do a better job.
There's a popular saying that states, "Too much of a good thing can be bad for you." I believe that's never been truer than now when it comes to EMR documentation.
Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate LOS, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
On October 1, 2013, the ICD-10-CM and ICD-10-PCSclassification systems will take effect, and should result in better data capture nationwide. The change means healthcare organizations urgently need to educate providers on the importance of improved patient care documentation.
