Proper “Coding” Necessary for Hospitals Receiving Bed Sore Reimbursement

By Nursing Home Law Center

Hospitals Proper Coding

The hospital chart of an elderly loved one can be a confusing morass of letters, scribbles and numbers. Yet the numeric “codes” on each person’s chart are essential to receiving proper Medicare coverage.

In a recent interview with The Hospitalist, two “documentation specialists” gave tips for understanding your loved one’s chart:

1. First, understand that universal “codes” are used by hospitals. The codes help the hospital’s internal “coders” submit an accurate claim to Medicare. Most codes are taken from the “ICD-9-CM,” or International Classification of Diseases. For example, even though nurses can give a “stage” (1-4) of a pressure ulcer, it must also be accompanied with the proper code in order for a patient to receive reimbursement.

2. If you’re confused about your loved one’s chart, ask to see a “Documentation Specialist”. “Documentation Specialists” are intermediaries between physicians and coders. “We’re just trying to help physicians capture the quality of care that they’re giving”, says Stephanie Jensen, RN, coordinator of the Clinical Documentation Integrity program at Omaha’s Nebraska Medical Center. “We want to make sure that, in the medical record, the documentation supports the severity of illness… and overall clinical picture”.

3. A useful acronym to know is a “DRG”, or “Diagnosis-Related Group”. “DRGs” number about 500, and are used by Medicare to determine the amount it should pay to hospitals. Patients in the same “DRG” tend to use similar amounts of hospital resources.

4. The more specific a physician can be in his or her diagnosis, the more good it will do patients. “If it’s not documented, it didn’t happen”, says Karen Bachman, BSN, director of clinical documentation at Good Samaritan Hospital in Suffern, NY.

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