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The present-on-admission (POA) indicator refers to conditions that are present at the time an order for inpatient admission occurs. Coders should report a POA indicator for a principal diagnosis, as well as any secondary diagnoses or E codes.
To assign POA, coders must rely on a treating physician’s documentation. Assuming physician documentation is accurate and complete, a coder can consider these tips when assigning a POA indicator: Read More→
The Office of Inspector General (OIG) will be searching for relevant information prudent to your hospital’s audit. This information is called evidence. To support your audit begin to collect four types of evidence before the OIG visits:
- Physical Evidence: Paraphernalia obtained through direct inspection of property, events, and people. (e.g., maps, photographs, illustrations, written summaries of observations, charts)
- Documentary Evidence: Created evidence including: spreadsheets, accounting records, contracts, invoices, letters, performance reports, and surveys.
- Testimonial Evidence: Information received through bias-free interviews and inquiries from individuals involved in the particular audit.
- Analytical Evidence: Collect analytical evidence through the verification of amassed information, facts, and data. Laws, legal and non-legal opinions, hospital standards, and past and present operations should all be compared to your analytical findings.
This week’s tip was adapted from The Healthcare Auditor’s Handbook, for more information about the book or to order your copy click here.
In January 2007, the University of North Carolina (UNC) Hospitals in Chapel Hill implemented a standardized, electronic assessment tool to aid its case managers in providing thorough and consistent patient assessments.
Beverly Wagner, RN, BSN, CCM, ACM, clinical care management educator at UNC Hospitals, and colleagues developed the tool with staff members to ensure their buy-in. The result was the brief assessment tool (BAT). The BAT made documentation easier and more consistent; patient assessment documentation rose immediately. “We had a nice surge from about 8% of discharges having measurable assessment documentation to about 30%,” says Wagner. “But we kind of hit a plateau there.”
Check out the September 2009 issue of Case Management Monthly to read the full article, and discover the benefits of becoming a Case Management Monthly subscriber.
Interview physicians regularly—either on the patient-care floor, during medical staff meetings, or while they are completing their records in your department. This will help you gain input into improving the process. For example, one interview may reveal that a physician would prefer the record completion area to have a small copier so he or she could copy progress notes and take them to his or her office billing staff. Once the copier is installed, it may be an inducement for the physician to stop by that area to complete his or her notes while copying records.
Editor’s note: This tip was adapted from HCPro’s book More With Less: Best Practices for HIM Directors, Second Edition.
Q: I am a case manager on a cardiac step-down unit. Our case managers’ work focuses primarily on l specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused.
We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?
A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document.
This question was answered by Karen Zander, RN, MS, CMAC, FAAN.
- Reviewing all Coding Clinic guidance dating back to the 1980s. Guidance regarding wound care coding has changed many times since Coding Clinic offered initial advice in 1988. Since then, it has published nine more clarifications. The most recent guidance came in Coding Clinic, in the third and fourth quarters of 2008.
- Implement standardized processes for documenting debridement. Pay particular attention to excisional debridement, as it typically falls under a higher-paying MS-DRG. During the demonstration project, the RACs focused on insufficient terminology in documentation.
- Track debridement cases at your facility. Especially focus on cases for which coders assign ICD-9 procedure code 86.22. Bryant said she started doing this in a homegrown spreadsheet within her system and continues to use coding compliance software to track this procedure information.
- Audit a random sample of patients coded with 86.22. Look for coding errors and fix any inaccurate claims. However, don’t change documentation in a medical record to prove excisional debridement, Bryant said. During a CMS RAC Open Door Forum in 2008, Bryant asked for clarification about how far back hospitals can change medical records. CMS responded that hospitals may amend documentation “in a timely manner,” but did not provide more information. Bryant urged caution here.
- Suggest the need for a standardized appeal letter. If the RAC claims that documentation in a medical record does not support ICD-9-CM procedure code 86.22, but you believe it does, “go back, look at the policy, look at the documentation, and appeal that case,” Bryant said.
Take advantage of two free tools to help you ensure your physician advisors are on top of their game, courtesy of the Association of Clinical Documentation Improvement Specialists (ACDIS).
Click here to download a sample physician advisor job description.
Click here to download a sample physician advisor documentation review program.
For further training on the roles and responsibilities of physician advisors, consider attending an upcoming audio conference “Clinical Documentation Improvement for Physician Advisors,” sponsored by the ACDIS. The April 14 audio conference will show you how physician advisors can make an enormous difference in improving initial documentation and physician response rates to queries; however the position must be structured correctly in order for it to work well. For more information on this audio conference, visit HCMarketplace.
Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
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