INPATIENT (IPPS) DOCUMENTATION TIPS FOR PHYSICIANS

By Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT

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1-24 - $24.95/book
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BETTY B. BIBBINS, MD, CHC, C-CDI, CPEHR, CPHIT

Why this handbook is written by a physician for physicians:

Inpatient (MS-DRG) documentation can be significantly different from Evaluation & Management (E&M) documentation. Physicians document acute care diagnosis, treatments, patient status & progress in the hospital setting. Coders only take the documented diagnoses and convert them to 5 digit codes (International Classification of Disease-9 [ICD-9]) that are submitted for data processing / reimbursement for services rendered. The 5 digit codes have to correlate to explicitly documented words within the medical record – and be present ‘verbatim’ when the medical record is reviewed by Auditors. Period. (Therefore a lab result is not a diagnosis.) Repeat: Physicians document, Coders code.