Undocumented policies and procedures are among the top five stumbling blocks to HIPAA compliance that Chris Apgar, CISSP, finds when he audits healthcare organizations.
Sometimes the best care a patient can receive in the ED is to not be treated there at all. They can often have treatment needs and do received meds, but that does not necessarily entail an admission.
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.
