Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used has to come from the physician in the progress note, or can this particular information be extrapolated from nursing notes, orders, etc.? Read More »
Medicare covers observation care as an outpatient service under Part B payments. (Medicare reimburses different healthcare providers under different systems or parts—Part A for hospital payments, Part B for medical/doctor’s services,...Read More »
After three years’ worth of frustration and postponements ICD-10-CM/PCS implementation seems to have been much ado about nothing (to quote Shakespeare). The October 1, 2015, implementation date has come and nearly a month has passed wherein the United States healthcare system lumbered on pretty...Read More »
Recovery auditors collectively identified and corrected more than a million claims for improper payments, resulting in $2.57 billion dollars being corrected, according to CMS’ fiscal year (FY) 2014 report on the recovery audit contractor (RAC) program.Read More »
This isn’t the first time we’ve heard about hospitals billing for Kwashiorkor, a form of severe protein malnutrition typically found in third-world countries that is extremely rare in the United States.Read More »
Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including...Read More »
