Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate length of stay (LOS), says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
Physicians and other providers practice in many different areas within a hospital. To accurately code physician and provider services, coders must know and understand the place of service (POS) codes.
As part of the 2013 OPPS final rule, CMS finalized a clarification to 42 CFR 419.2(b) that could cause confusion in the future if hospitals are audited by third-party payers or by Medicare contractors who do not fully understand the intent of the language or how CMS develops payment rates, says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, D.C.
