Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate length of stay (LOS), says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
One of the major changes to the 2013 CPT Manual is the replacement of the term "physician" with "physician or other qualified healthcare professional" (QHP) in a wide range of codes.
