Inpatient or observation? Making this decision remains a considerable challenge at many hospitals—and when they get it wrong, it can also be a costly one.
Cancer Treatment Centers of America and Midwestern Regional Medical Center (CTCA) based in Zion, Illinois, reported a breach last month potentially affecting 104,808 individuals, according to the Office for Civil Rights (OCR) breach report.
Regular monitoring and internal auditing are critical to ensure compliance throughout the revenue cycle and protect revenue integrity. Consider the different strategies that can be applied to documentation and chart audits, coding audits, and more.
The most impactful overhaul to the E/M coding and documentation guidelines in 25 years went live January 1. The updated guidelines eliminate medical history and physical examination as required elements for reporting E/M codes 99202-99215. E/M coding for outpatient visits is now based on documentation of medical decision-making (MDM) or time spent on the encounter.
Medical decision-making is one of the key components of E/M code selection. Review the guidelines to ensure correct coding and to improve internal audits.
