It's a scenario that plays out at hospitals across thecountry each day. A Medicare patient is scheduled for a procedure typically performed on an outpatient basis. But the patient has a number of preexisting health conditions, such as chronic obstructive pulmonary disease or diabetes, which are going to make the surgery and recovery more complicated.
Determining whether a patient should be an inpatient or on observation services can be a challenging call. If the wrong decision is made or the right decision isn't properly documented, the claim will likely be denied.
Gloryanne Bryant, RHIA, RHIT, CCS, CCDS, regional managing director of HIM (Northern California Revenue Cycle) for Kaiser Permanente in Oakland, compiled a sample list of some of the terms coders are likely to see when coding for wound care. Consider sharing this reference tool with your coding staff.
Over the course of the past 30 years in the HIM field, I have observed much trial and error on the part of HIM managers who have been pioneers in the EHR journey.
Editor's note: In 2011 we're celebrating MRB's 25th birthday with special content each month. For October, we've put together a report on the latest quarterly benchmark survey findings, this time on ICD-10 implementation efforts. Just a few of the highlights from the report are included below.
