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.
HIPAA privacy officers don’t have eyes in the back of their heads. Nor can they be everywhere at once. But they can increase their ability to monitor compliance by sharing the responsibility with other staff members.
The frequency of CMS surveys seems to be on the rise. With that in mind, I thought I would address three of the top medical record concerns that might plague you if CMS comes knocking on your HIM department’s door. We have covered these in past columns, but it never hurts to take another look at the big three: verbal orders, history and physical reports (H&P), and post-anesthesia evaluation.
