Like other services covered by Medicare, observation must be reasonable and necessary or, in other words, medically necessary. The physician must document that they assessed patient risk to determine that the patient would benefit from observation services.
The American Medical Association (AMA) announced on March 26 new CPT coding and reporting guidance for physicians and medical practices, intended to simplify reporting of in-person and online visit services for novel coronavirus (COVID-19) patients.
With the release of a new ICD-10-CM code for the novel coronavirus (COVID-19), hospitals now have a method to capture and report this critical disease. Although the code itself is relatively straightforward and likely won’t stir up confusion the way coding for complex diagnoses (such as sepsis) does, correctly documenting and coding COVID-19 is crucial to turning the tide on the national public health emergency.
The American Thoracic Society and Infectious Diseases Society of America recently published guidelines for the diagnosis and treatment of adults with community-acquired pneumonia. The updated guidelines are an attempt to better identify patients at risk for pneumonias due to multidrug-resistant bacteria such as Gram-negative rods and methicillin-resistant Staphylococcus aureus.
Q: When a physician needs to certify an inpatient stay of 20 days or more, do we need to use a specific form for the certification? Or can we submit other documentation such as the physician's notes from the medical record?
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
Take a look at some common questions asked about MS-DRG optimization and review how inpatient coding and documentation plays a significant role in the process. Learning the ins and outs of this process will ensure that your facility remains educated and compliant.