The implementation of an EHR is a multifaceted, comprehensive project for healthcare organizations. To avoid coding issues during EHR implementation and ensure discharged-not-final-coded is not adversely impacted, dedicated HIM focus and detailed project planning are paramount.
An OIG audit of the University of Michigan Health System revealed noncompliance with four types of inpatient claims, including those associated with billing of DRGs, and two types of outpatient claims, including those billed with modifier –59 (distinct procedural service).
Historically, the social work profession resisted the change from manual documentation to template-based tools, but with the growing emphasis on quality and reducing hospital readmissions, social workers need to utilize case management assessments as a way to communicate risk and pertinent patient details.
As healthcare organizations navigate an increasingly complex regulatory environment, leaders at various levels—particularly HIM, release of information (ROI), compliance, finance, health information technology (HIT), privacy, and security—face unprecedented challenges.
Q: What should we report if you have a compression dressing that was applied to the thigh, in addition to the lower leg, since CPT code 29582 (multi-level compression bandage application, thigh to foot) was deleted for 2018?