Corporate Compliance

Improve compliance with a clinical documentation program

Strategies for Health Care Compliance, November 1, 2008

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How can coders ensure that they assign the correct present-on-admission (POA) indicator? How can auditors make sure they are prepared when the recovery audit contractors come? How can billers avoid claim denials? Clear and accurate documentation is the answer, says Lynne Spryszak, RN, coordinator of the clinical documentation management program at Alexian Brothers Medical Center (ABMC) in Elk Grove Village, IL.

Clinical documentation specialists (CDS) are becoming an increasingly more common part of the staff at medical facilities. At ABMC, a CDS reviews charts for all Medicare inpatients, checking for “a documented diagnosis for every condition being evaluated, treated, or monitored,” Spryszak says.

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