ED Documentation and Coding Update Archives
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How better nurse documentation can boost your bottom line
If the nursing documentation in your emergency department is lacking key information, your facility may not be getting all the reimbursement it deserves. More ominously, inadequate nursing documentation can open the door for costly legal action down the road.Use this checklist when you document
You should include the following items in your documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA.Documenting restraints: What you need to know
Because the practice of placing a patient in restraints or somehow isolating that patient is scrutinized so carefully not just by the Centers for Medicaid & Medicare Services and the Joint Commission but by internal hospital committees and patients families as well its vitally important for you to be able to document what you did, why you did it, and how often you followed up.Use better documentation to head off ED errors
Its no secret that the fast-paced and often crowded environment at many emergency departments can pose problems not faced in other, more sedate levels of care. And its perhaps no surprise that many of the factors that cause inadequate documentation in the ED also can lead to medication errors.USP lists most frequent medication errors in ED
Because the ED typically is organized to deliver prompt, life-sustaining care, its role, purpose, and function differ from other patient care areas, according to Rockville, MD-based U.S. Pharmacopeia. The combination of interruptions, intense pressure, and a fast-paced environment can lead to medication errors and fewer error interceptions.Leapfrog Group to help hospitals with investments
A member of the steering committee of The Leapfrog Group, a Washington, DC-based patient safety organization, said the committee is developing plans to help hospitals recoup some of the money they invest in changes to meet Leapfrog recommendations.The Documentation-Coding Connection: Benchmarking ED physician billing
Its a common practice to benchmark physician-billing patterns against those of peer groups. Unfortunately, benchmarking against such data is misleading, since it is based upon three incorrect assumptions.The Documentation-Coding Connection: Billing and documenting critical care
When does critical care become just another emergency department visit? When you fail to document it properly. You may do all the right things and have a patient in crisis, but if the paperwork isnt done properly, you dont get paid for your efforts.The Documentation-Coding Connection: CPT-4 coding inconsistent; templates could help
Agreement in coding of emergency charts between coding agencies used by one hospital system was only poor to fair, and the distribution of assigned CPT-4 codes was significantly different among the agencies, according to a study from William Beaumont Hospital System in Royal Oak, MI, published in the Annals of Emergency Medicine.The Documentation-Coding Connection: CMS issues HIPAA checklist for providers
The Department of Health and Human Services' Centers for Medicare and Medicaid Services has issued a checklist to help health care providers who do business electronically and their business partners to comply with the administrative simplification requirements of the Health Insurance Portability and Accountability Act.