Beatrice, 66, arrives at the long-term acute care (LTAC) hospital with end-stage renal disease (ESRD), hemodialysis, malnutrition, a stage IV coccyx decubitus ulcer, depression, and no family support.
As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and implementing a revised encoding system. This will probably be one of the biggest transitions hospitals and HIM directors and coders have seen in many years.
Medically unnecessary services and incorrectly coded items had the highest amounts of RAC overpayments collected in the demonstration project, according to CMS.
