Health Information Management

Take another look at observation documentation

HIM-HIPAA Insider, February 17, 2009

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As with most reimbursement challenges, appropriate documentation plays a significant role in whether Medicare will pay for or deny claims for observation patients. For observation status, documentation should include two important components:
  • Admission, discharge, and other important progress notes, written, timed, and signed by the physician.
  • Documented risk assessment. The physician needs to state outright any reasons he or she believes the patient needs constant care and observation, Hoy says. The chart should include proof that the physician didn’t simply admit the patient to observation overnight, check in the next morning, and then discharge the patient. CMS requires continued assessment and reassessment. This is one area in which a focused documentation improvement effort is advantageous, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA.
Editor’s note: This tip was adapted from the February issue of Briefings on Coding Compliance Strategies.



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