Q: If our physician only documents “uncontrolled diabetes” in an admitted patient’s chart, but I can see from the lab results in the record that the patient’s blood glucose levels are high, can I go ahead and assign the ICD-10-CM code for diabetes with hyperglycemia?
Q: I’m a registered nurse, and I received treatment at the ER of the hospital where I work. When I asked for a return-to-work note the next day, the physician told me that my supervisor called her the previous evening and asked if I had asked for the note. Is this a HIPAA violation?
This week's note from the instructor delves into an issue with inpatient-only procedures that may result from wording in the 2019 Inpatient Prospective Payment System (IPPS) final rule.
HHS failed to meet targeted improper payment reductions for Medicaid and the Children’s Health Insurance Program and has not implemented a required recovery audit plan for Medicare Advantage, according to an Office of Inspector General (OIG) report.
