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.
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.
With 46% of survey respondents anticipating revenue losses from the ICD-10 transition, it may appear illogical that only 3% of healthcare leaders say they are already prepared to make this transition. However, the reason behind the unpreparedness is quite understandable. With mounting mandates and competing priorities, healthcare leaders say they cannot free up the manpower or financial resources needed to get this initiative under way.
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.
