Beatrice, 66, arrives at the long-term acute care (LTAC) hospital with end-stage renal disease (ESRD), hemodialysis, malnutrition, a stage IV coccyx decubitus ulcer, depression, and no family support.
Increased ED volumes, changes in regulatory requirements, the required use of observation, and added scrutiny from the recovery audit contractors have made implementing an ED case management model essential.
At Cabell Huntington (WV) Hospital (CHH), case managers are more than just chart reviewers, they are part of the physician team—a shift in perspective that improved the facility’s LOS and, arguably, its patient care.
Preadmission Screening and Resident Review (PASRR) is a federal mandate that protects individuals with serious mental illness (SMI) or mental retardation (MR) from placement in facilities that can’t provide their specialized level of care. The screen also determines whether patients are capable of living independently.
As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and implementing a revised encoding system. This will probably be one of the biggest transitions hospitals and HIM directors and coders have seen in many years.
