With the release of a new ICD-10-CM code for the novel coronavirus (COVID-19), hospitals now have a method to capture and report this critical disease. Although the code itself is relatively straightforward and likely won’t stir up confusion the way coding for complex diagnoses (such as sepsis) does, correctly documenting and coding COVID-19 is crucial to turning the tide on the national public health emergency.
Like other services covered by Medicare, observation must be reasonable and necessary or, in other words, medically necessary. The physician must document that they assessed patient risk to determine that the patient would benefit from observation services.
Sepsis hospitalizations are on the rise and cost Medicare more than $40 billion in 2018, according to a U.S. Department of Health and Human Services (HHS) study.
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?
Conflicting provider documentation can raise red flags for auditors and slow down coding. Learn about common causes of conflicting documentation and strategies to reduce its occurrence.
