One setting alone doesn’t possess all the services required to fulfill a patient’s needs. Employees at each setting have different talents, skills, and knowledge needed to achieve all the care needs.
One of the most important aspects of documenting your evaluation and treatment of inpatients in the medical record is providing the verbiage that meets your goals for describing your patient. When you provide the right words, the coders assign the right codes.
The electronic Program for Evaluating Payment Patterns Electronic Report (PEPPER) contains data for hospitals on MS-DRGs and discharges at high risk for payment errors. Per the opening paragraph of the 2010 PEPPER User’s Guide:
As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. PEPPER can help guide the hospital’s auditing and monitoring activities.
ARRA brought us an expanded version of HIPAA. Along with it came the clear message that if the last time you visited your HIPAA policies and procedures was April 15, 2005, you have a problem.
I have received several questions related to my “Standards of the month” column about history and physical (H&P) reports.
I thought it would be a good idea to clarify two specific issues these inquiries raised: 1) the requirements for H&P examinations for moderate sedation, and 2) allowing anesthesiologists to complete the update to the H&P report prior to surgery.
