Q: When a physician needs to certify an inpatient stay of 20 days or more, do we need to use a specific form for the certification? Or can we submit other documentation such as the physician's notes from the medical record?
Take a look at some common questions asked about MS-DRG optimization and review how inpatient coding and documentation plays a significant role in the process. Learning the ins and outs of this process will ensure that your facility remains educated and compliant.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.