A lot can go wrong when an elderly patient is discharged home, from medication errors to transportation problems or self-care comprehension issues. However, an organization can create a solid discharge and transition process by focusing on some simple elements.
Organizations often struggle to finalize charts after discharge so they can be coded in a timely manner, but this process can be completed efficiently with direction from HIM professionals and coordination between departments.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
The January quarterly I/OCE update includes new modifiers, changes related to expanded packaging, and continued refinement of CMS' skin substitutes categories, but the biggest change for outpatient hospitals is the implementation of comprehensive APCs (C-APC).
RC.01.01.01, Content of the Medical Record, did not top the list of survey findings for hospitals in the first half of 2014, according to the September 2014 issue of Joint Commission Perspectives. Nor was it on the list for critical access hospitals at all! However, 49% of hospitals surveyed received a requirement for improvement for this standard, primarily in the EPs related to timing and dating entries. This indicates hospitals are still using a lot of paper records. That said, the downward swing is encouraging as more and more hospitals fully implement the EMR.
Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
