Observation services are a specific set of services provided to a patient while the physician decides whether to admit or discharge the patient. That means if a patient undergoes a procedure that requires “active monitoring,” he or she is not receiving observation services during the procedure.
It will take time for coders to become comfortable translating terminology used in physician documentation to root operation terminology used in ICD-10-PCS, according to Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, who spoke during HCPro’s November 18, 2010, audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.” But Jones thinks coders will get there eventually.
In 2010, HCPro’s Revenue Cycle Institute conducted its second annual in-depth study on RAC preparedness among healthcare providers. The results are now in: RAC audits have picked up, but preparation and education are still under way for many, and HIM plays an important role.
I promised in a previous “Standards of the month”column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.
After 10 years, the requirements for signatures on lab requisitions are still in flux; CMS published the latest change to the lab signature requirements in the 2011 Medicare Physician Fee Schedule (MPFS) final rule published in the Federal Register November 29, 2010.
