“In my opinion, [ICD-10 implementation] is the biggest change in healthcare since the implementation of DRGs back in the early ’80s,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. McCall and Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, spoke during HCPro’s November 18 audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.”
The last thing you need is more to do, but when it comes to preparing your HIM department for EHR go-live, an ounce of prevention is worth a pound of cure.
Methodist South Hospital in Memphis, TN, began using the Situation, Background, Assessment, and Recommendation (SBAR) tool to meet two basic needs: standardizing communication across the facility and managing complex cases.
Families often have to make difficult decisions when a loved one is in the ICU, and they rely on hospital case managers and social workers for support and information.
There are specific MS-DRGs, called transfer DRGs, that can trigger certain transfer rules that cause a hospital to receive a reduced rate for early discharges to specific locations.
Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.
