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Top 10 Documentation and Coding Issues for Hospitals in 2021

Make sure you are addressing these top documentation and coding compliance concerns.

  1. Risk-based review of inpatient DRG cases, examples include:
    1. RAC DRG targets; PEPPER targeted DRGs
    2. COVID related inpatient discharges
    3. Clinical indicators, cases at risk for clinical denials (e.g. Sepsis, CHF, ARF, severe malnutrition, encephalopathy)
    4. IP cases with only 1 MCC/CC code or HAC/PSI cases
    5. IP short stay cases (24-48 hours) with complex principal diagnosis (e.g. Sepsis, AKI, ARF)
    6. Expired patients with risk of mortality (ROM) level 1, 2, or 3
    7. DRGs 981-983 surgical procedure unrelated to principal diagnosis
    8. Complex surgical procedures such as spinal infusions, open heart surgeries, and/or intestinal excision and resection procedures
    9. Discharge Disposition accuracy for DRGs subject to being paid under the Medicare Post-Acute Care Transfer Rule
  2. Short stays, inpatient readmissions, and three day Skilled Nursing Facility Qualifying Admissions (ensure compliance with admission criteria and 2-Midnight rule)
  3. Clinical indicators, specific to the patient and episode of care, must support queries. Review physician queries to assure query language is compliant and not leading.
  4. Infusion and injection coding (including J codes with correct units charged, drug wasting, and JW modifier)
  5. Interventional radiology and interventional cardiology procedure coding and billing
  6. Outpatient Dialysis claims to ensure compliance with Medicare requirements
  7. Facet joint injections (CPT 64490-64495) inclusive of fluoroscopy CT guidance and contrast injection
  8. Outpatient Cardiac and Pulmonary Rehabilitation meet medical necessity and comply with certain documentation requirements
  9. NICU (ensure clinical documentation meets medical necessity for NICU level of service)
  10. Data mining to identify trends/outliers (e.g. high utilization of certain DRGs, unspecified diagnosis codes or procedure codes, identify and follow up on trends in claim denials)

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