Imagine a hospital as a sentient being that holds within it all things necessary to heal you from illness or injury. The HIM department, or medical records department, is this being's memory. Without it, there would be no continuum of patient care. Sometimes, it's the hospital's memory that serves to produce an otherwise overlooked diagnosis.
The healthcare industry is changing rapidly, and if you've been paying attention to the news you've probably noticed the recent wave of hospital mergers.
Doctors might know what's best for their patients, but patients don't always choose to follow that advice. Over these past few issues, CMM has talked about CMS' new suggested best practices, which were included in revisions to the discharge planning section of the CMS State Operations Manual. These new recommendations call on facilities to carefully investigate patients' refusals to heed medical advice and document their reasons for doing so. However, there is more you can do when a patient balks at a physician's instructions, says Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, senior director of case management at West Region Kindred Healthcare, Hospital Division.
CMS added modifier -AO (provider declined alt payment method) and new HCPCS codes to the I/OCE as part of the October 2013 quarterly update found in Transmittal 2763.
Despite its apparently straightforward definition in the CPT® Manual, modifier -59 (distinct procedural service) can be deceptively difficult to append properly.
