Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
Probably the most onerous duty physicians have is the preparation of the inpatient discharge summary, especially after a long or complicated hospital stay.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
Pneumonia discharges impact hospital payments under the Hospital Value-Based Purchasing Program as well as the Hospital Readmissions Reduction Program. The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in the measure.
The Office for Civil Rights (OCR) released guidance on patient access fees with little fanfare last year but the guidance, intended to clarify existing OCR regulations, became a flashpoint for controversy. The guidance states that organizations may charge a patient either a flat fee of $6.50 or follow a specific methodology for calculating the cost of making a copy of requested patient records. Although some organizations found their fee schedules out of step with OCR’s guidance, the biggest problem came from an unexpected corner: attorneys.
