RE: cdi_talk digest: October 21, 2011
Don, regarding your possible project, I would recommend looking at some
of the QIO websites to see if they have tools you could use. I believe
if you approach this from the physicians' documentation needs for
reimbursement, it will increase buy-in.
How many body systems are mentioned in the Hx of Present Illness (HPI)?
What areas or problems have they addressed on a daily basis and have
they provided diagnostic specificity? In order for them to bill the
highest level of Evaluation and Management (E & M), they must meet
certain criteria. I would look at some of those tools, and talk with you
coders, to come up with a list that would be mutually beneficial to the
hospital and the physician. I would make the point that bundled payment
will require that hospitals and physicians work collaboratively, and
then ask how you can help him to meet the appropriate E&M level. Just my
thoughts, but I definitely applaud you for this and have tried to get
something similar together myself. I want to develop a template or
tip-card that will fit in their pocket that will have exactly these
sorts of questions and then cross-reference those tips to their E&M
coding. I had a draft I was working on some time ago, but haven't had a
chance to get back to it. If I can find it I'll send it to you. Just
remember, it is a work-in-progress.
Sandy Beatty, RN, BSN, CCDS
Clinical Documentation Specialist
Clinical Quality Management
Columbus Regional Hospital
2400 E. 17th Street
Columbus, IN 47201
sbeatty@crh.org
of the QIO websites to see if they have tools you could use. I believe
if you approach this from the physicians' documentation needs for
reimbursement, it will increase buy-in.
How many body systems are mentioned in the Hx of Present Illness (HPI)?
What areas or problems have they addressed on a daily basis and have
they provided diagnostic specificity? In order for them to bill the
highest level of Evaluation and Management (E & M), they must meet
certain criteria. I would look at some of those tools, and talk with you
coders, to come up with a list that would be mutually beneficial to the
hospital and the physician. I would make the point that bundled payment
will require that hospitals and physicians work collaboratively, and
then ask how you can help him to meet the appropriate E&M level. Just my
thoughts, but I definitely applaud you for this and have tried to get
something similar together myself. I want to develop a template or
tip-card that will fit in their pocket that will have exactly these
sorts of questions and then cross-reference those tips to their E&M
coding. I had a draft I was working on some time ago, but haven't had a
chance to get back to it. If I can find it I'll send it to you. Just
remember, it is a work-in-progress.
Sandy Beatty, RN, BSN, CCDS
Clinical Documentation Specialist
Clinical Quality Management
Columbus Regional Hospital
2400 E. 17th Street
Columbus, IN 47201
sbeatty@crh.org