Now that the problems have been identified, recommend steps to improve documentation for reimbursement issues.
You are the HIM manager for Happy Medical facility. In your monitoring of the facility’s compliance activities, you realize that your organization has a problem with denials for documentation. Your staff has reviewed the health records as well as the denials letters.
The top four problems identified were the following:
• History and physicals (H&Ps) do not meet medical staff bylaws for time of completion and content
. • Discharge summaries do not meet Joint Commission, Centers for Medicare and Medicaid guidelines for documentation, and medical staff regulations for completion and content.
• Progress notes are very brief and do not adequately describe the patient’s improvement or lack thereof.
• The diagnoses do not provide specificity.
Now that the problems have been identified, recommend steps to improve documentation for reimbursement issues.
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