In 2008, only 11% of respondents to an Association of Clinical Documentation Improvement Specialists (ACDIS) poll indicated their clinical documentation improvement (CDI) programs either reviewed outpatient records for documentation improvement opportunities or were looking to expand into outpatient areas (8% and 3% respectively).
Revenue cycle leaders, including HIM professionals, are aware that a patient billing or collection problem can destroy what had up to that point been an exceptionally positive clinical experience. With the ever-expanding reach of social media, a patient who is dissatisfied with a billing or collection problem may be more likely to share that problem with others rather than sharing private details about clinical problems.
The Medicare Transitional Care Act of 2014 would require Medicare to provide payment for approved transition services designed to move patients safely to the next level of care.
Coders have only two options for reporting fractures of the patella in ICD-9-CM, closed (822.0) and open (822.1). In ICD-10-CM, that number will jump to more than 400.
Many of these options are the result of separate codes to denote laterality (right or left) in ICD-10-CM. However, the code set also includes options for specific types of fractures, increasing the importance of clear and accurate provider documentation.
"Sometimes the questions are complicated and the answers are simple." ?Dr. Seuss
This quote seemed an appropriate way to begin a discussion about outpatient encounters and ICD-10-PCS.
You see, outpatient procedures will still be coded using CPT®/HCPCS?the HIPAA-approved code set for reporting hospital outpatient procedures?regardless of when ICD-10 is implemented.
The intent of quality and safety programs is evaluating and monitoring performance and improving results. Organizations develop annual quality and safety plans with measurable objectives that departments adopt and include as integral to their performance improvement plans.
