“Did of Out?” · $10.6M $3.9M $1.6M $357,000 $160,000 $1.7M $204,000 $470,000 $0 $5 $10 $15 $20 $25 $30 $35 $40 $45 GSR Ortho NSR POD MAX GYN GU ENT Millions Claims/qtr for each

©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

2

“Did You Take All of That Out?”:Preparing Surgeons for ICD‐10‐PCS Documentation RequirementsGwen Regenwether, BSN, RN

Cheree Lueck, BSN, RN

Clinical Documentation Specialists

Denver Health and Hospital Authority

Denver, Colorado

3

Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Examine potential impact of ICD‐10‐PCS implementation on facility cash flow

– Define a process for analysis of current performance and vulnerabilities

– Identify an educational plan of action and process for monitoring and providing feedback

– Describe how to organize collaboration between CDI and coding departments to facilitate the transition to ICD‐10‐PCS


4

Why Is ICD‐10‐PCS Important?

• Higher‐quality/quantity data

• Up to date with emerging procedures

• Multitude of codes for more specificity

5

What’s at Risk With ICD‐10‐PCS?

Decreased cash flow by delaying the claim submission to the payer

6

Denver Health and Hospital Authority

• Level one trauma center

• 525‐bed hospital

• Community‐ & school‐based clinics

• 451 attending physicians

• 177 advanced practice providers

• 1,000+ residents

• University of Colorado School of Medicine


7

2014 Denver Health Medical Center

• 25,000 hospital admissions

• 3,300 deliveries

• 10,000 surgeries

– 4,000 inpatient

– 6,000 outpatient

$201M in uncompensated care

8

9

CDI at Denver Health

• Established in 2008

• 5 CDI RNs

• 1 data analyst

• Physician director

– 3 physician advisors


10

Our CDI Focus

• Collaborate with coding, quality & safety, and care management departments

• Retrospective audits

– Medical necessity

– Surgical operative reports

11

Coding Limitations of ICD‐9

Displaced fracture of right femoral shaft, reduced & fixated using an open reduction internal fixation (ORIF)

79 Reduction of fracture and dislocation

79.0 Closed reduction of fracture without internal fixation

79.1 Closed reduction of fracture with internal fixation

79.2 Open reduction of fracture without internal fixation

79.3 Open reduction of fracture with internal fixation

79.35 Open reduction of fracture with internal fixation: femur

79.4 Closed reduction of separated epiphysis

79.5 Open reduction of separated epiphysis

79.6 Debridement of open fracture site

12

Coding Limitations of ICD‐9

• 4–5 numerical characters

• Limited expansion

• Lack of specificity

• No laterality

• Code assignment dependent on text descriptor


13

ICD‐10‐PCS Coding

SectionBody system

Root operation

Body part

Approach Device Qualifier

1 2 3 4 5 6 7

14

0 Medical/Surgical SECTIONQ Lower Bones BODY SYSTEMS Reposition ROOT OPERATION

Body part Approach Device Qualifier

6 Upper Femur, Right7 Upper Femur, Left

8 Femoral Shaft, Right9 Femoral Shaft, LeftB Lower Femur, RightC Lower Femur, Left G Tibia, RightH Tibia, LeftJ Fibula, RightK Fibula, Left

0 Open3 Percutaneous4 Percutaneous Endoscopic

4 Internal Fixation Device 5 External Fixation Device6 Internal Fixation Device, IntramedullaryB External Fixation Device, MonoplanarC External Fixation Device, RingD External Fixation Device, HybridZ No Device

Z No Qualifier

0QS804Z

ICD‐10‐PCS Coding

15

Method

April–

July

Baseline audits

Initial provider education

August–September

Ongoing audits

Educational tools

October–December

Final audits post intervention


16

What Triggers a Query?

SectionBody system

Root operation

Body part

Approach Device Qualifier

17

Baseline Audit for General SurgeryApril 2014–July 2014

18

Baseline Audit for All SpecialtiesApril 2014–July 2014


19

How Does This Affect Billing?

• Denver Health surgical facility claims = 60%

• Q2 2014

– $192M inpatient claims

– $115M surgical

• Query rate of 23% = $19M/qtr

– Facility claims that would be delayed

20

$10.6M

$3.9M

$1.6M$357,000 $160,000

$1.7M

$204,000$470,000

$0

$5

$10

$15

$20

$25

$30

$35

$40

$45

GSR Ortho NSR POD MAX GYN GU ENT

Millions

Claims/qtr for each service line

Difference Total cost in delay

21

GSR Query Rate by PCS Character

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Section BodySystem

RootOperation

Body Part Approach Device Qualifier


22

Overall Query Rate by PCS Character

0%

10%

20%

30%

40%

50%

60%

Section BodySystem

RootOperation

Body Part Approach Device Qualifier

23

Body Part –A Colon Isn’t Just a Colon in ICD‐10 …

24

Gastrointestinal System Body Parts

H – Cecum

J – Appendix

K – Ascending colon

L – Transverse colon

M – Descending colon

N – Sigmoid colon

P – Rectum


25

Approach – Transsphenoidal Resection of Pituitary Tumor

“The long silver speculum was inserted into the nose and through the right nostril. The Stealth probe was extremely helpful in identifying the anatomy. The Hardy

speculum was then inserted and expanded. Additional mucosa inferiorly and laterally was removed, exposing the opening into

the sphenoid sinus.”

26

Root Operation

“He was brought to the operating room today to do an excisional debridement of the plantar and lateral aspect of the sulcus region including bone of the left hallux with

washout.”

27

Devices

• Surgeons = tool used to perform surgery

• Coders/CDI = devices inserted and remaining inside the patient after surgery has finished

– Biological or synthetic material that takes the place of all or a portion of a body part, such as a skin graft or a joint prosthesis

– Biological or synthetic material that assists or prevents a physiological function, such as an intrauterine device

– Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part, such as a radioactive implant

– Mechanical or electronic appliances used to assist, monitor, take the place of, or prevent a physiological function, such as a cardiac pacemaker or orthopedic pin


28

Physician Interventions

Specifying body parts Right or left Upper, middle, or lower Greater or lesser

Documentation example“Blunt finger dissection was carried down to the bicipital groove, we then removed all of the right long head biceps tendon.”

Always document: The specific anatomical location(s) of where the procedure is

taking place Laterality

(left, right, or bilateral) Exactly how much of the body part was removed

(all, partial, or measurements) Specify actual body cavities rather than referring to

abdominal quadrants Document if specimens sent to pathology are intended to

diagnose and help with treatment decisions following the procedure

Body parts

29

Physician Interventions

• Educational lunch meetings with residents

• Online modules

• Dictation card updates

• Bonus incentive program for physicians

OPERATIVE REPORT FORMATDISCHARGE/INTERIM/SHORT STAY SUMMARY

FORMAT

Dictating physician name & # 1 Dictating physician name, # and team name

Pt name, MRN #, and FIN # 2 Full attending name

Date of Surgery 3 Pt name, MRN #, and FIN #

Attending MD Name 4Admission and Discharge Dates‐Identify discharge status: home, home with home health, correctional care, or SNF

Additional MDs Names 5

ALL Actively Managed Diagnoses, prioritized (Do NOT designate as principal/secondary)‐Link diagnoses, specify, use stages of illness and acute/chronic where applicable, identify laterality.

Pre‐op Dxs 6 Comorbidities not actively managed

Post‐op Dxs 7 ALL invasive procedures, excluding radiography

Specimens sent to pathology.‐Must specify specimens for diagnosis, and if it was the complete body part or only partial.

8Brief H&P: 1‐3 sentences summarizing initial presentation then dictate, “See initial H&P for details”

Estimated blood loss 9

Concise hospital course by problem. 1st line of hospital course should identify: ‐Why did the pt require inpatient vs. obs care‐What was the risk if patient didn’t get this level of care‐What were the main objectives of admission (i.e., goals for discharge)

Anesthesia 10Do NOT list meds; dictate, “See medication reconciliation form”

Operative indications/Intent of surgery 11Medication changes, i.e., new meds, DC’d meds, dose changes

Procedure(s) performed 12

Disposition/Follow‐up plan‐Condition of pt at time of discharge‐Follow‐up appts and time frame‐Important items for F/U at 1st appt, pending labs and studies

Procedure Narrative 13 Interim summaries should include #1‐6 only.

Device(s) Implanted 14Copies to non DH provider, if applicable. Must include fax # in CC.

Explain deviations from planned procedure.

‐What was done?

‐Was it avoidable?

‐Was standard treatment altered?

15

Always specify body parts and laterality. 16Contact Clinical Documentation Integrity for questions regarding proper documentation.

The Discharge Summary is a vital part of the chart summarizing care. This is the key to clarifying why the

patient merited the level of care the received.

30

All Specialties After InterventionsOctober 2014–December 2014


31

Annualized amount of claims prevented from delay

32

Collaboration With Coding Department

• PCS coding practice

• Coding Clinic submissions

• Facility coding guidelines committee

33

Coding Clinic SubmissionsDetachment of the Thumb

http://www.clker.com/clipart‐49541.html


34

Coding Clinic Submission Approach – Open Irrigation

3 – Percutaneous

X – External

7 – Via natural or artificial opening

8 – Via natural or artificial opening Endoscopic

35

Facility coding guidelines committee

36

Summary

Collaboration

Knowledge

Engagement

Queries


37

Keep the momentum!

38

References

• ICD‐10‐PCS: The Complete Official Draft Code Set. (2015). Salt Lake City, UT: Optumlnsight, Inc.

• ICD‐10‐PCS Reference Manual. (2012). Denver, CO: Haugen Consulting Group, Inc.

• Code It Right: https://aafp.codeitrightonline.com/ciri/icd‐10‐pcs‐medical‐and‐surgical‐root‐operations‐that‐always‐involve‐devices‐part‐2.html

39

Thank you. Questions?

[email protected]@dhha.org

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

Additional credit to:Norma Stiglich, MD, OBGYN

Megan Buyrn, BSN, RNMary Kate Rentschler, MBA, BSN, RN

Pence Livingston, BSN, RNNathan Brainard, BS

ICD10 Procedure ICD10 Procedure

Documentation Tips for Documentation Tips for

General SurgeryGeneral Surgery

Intent vs. Indications

Indication for cholecystectomy

is symptomatic gall stones.

Intent of the procedure is to

remove the gallbladder.

Documentation Example

“The patient presented with

right upper quadrant pain, with

history of gallstones, and

unable to tolerate oral intake.

The patient was advised to

have her gallbladder removed.

We performed an urgent

Cholestectomy.”

Define the intent the intent of the procedure; not just the

indication(s) for the procedure.

Coders must have a clear understanding of the intent of the

procedure in order to decide what root operation will be used for

the code. The root operations are a series of definitions used by

the coders to identify the type of procedure performed. It must

be understood that explaining the intent of the procedure will

help the coders to properly assign the appropriate root

operation.

Intent of ProcedureIntent of Procedure

Specifying Body Parts

Right or left

Upper, middle or lower

Greater or lesser


“Blunt finger dissection was

carried down to the bicipital

groove, we then removed all of

the right long head biceps

tendon.”

Always Document:

The specific anatomical location(s) of where the procedure is

taking place.

Laterality

(Left, right or bilateral)

Exactly how much of the body part was removed.

(All, partial or measurements)

Specify actual body cavities rather than referring to

abdominal quadrants.

Document if specimens sent to pathology are intended to diagnose

and help with treatment decisions following the procedure.

Body PartsBody Parts

Types of Devices

Grafts and Prostheses

Implants

Simple or Mechanical

Appliances

Electronic Appliances


“A 7-French single J stent over

a super stiff wire was placed in

both the right and left renal

pelvises through our

ureteroileal anastomosis. They

were passed easily and we

were confident they were in

the renal pelvises.”

Anything that is left in the body after the procedure is considered a device.

Surgical tools and instruments used to perform the procedure are not

considered a device for ICD10 PCS.

Always Document:

The specific anatomical location(s) of the device.

If a catheter or tubal device is used, documentation must include the body part

where the tip of the catheter is finally placed.

The intended purpose of the device.

Document if the device is placed for the 1st time, removed or replaced.

Document the type of device; biological, autologous, non-autologous, or synthetic

substitute. Documentation can also refer to device descriptors or brand names.

ImplantedImplanted DevicesDevices

Types of Debridement

Excisional– Surgical

removal or cutting away

devitalized tissue using a

blade or scalpel.

Non-excisional– Cleaning,

brushing, scrubbing,

washing or irrigating of

wound.


“Attention was directed to the wound overlying

the lateral aspect of the 5th metatarsal on the left

foot. His wound measured approximately 1.5cm in

diameter and 3cm in depth with a fibrotic base.

Utilizing a scalpel, the wound was debrided down

to 3cm in depth, to good bleeding in the

subcutaneous tissue. The excision did extend

about 2cm beyond the wound margins. The most

dorsal aspect of the wound was freed from the

bony attachment to the base of the 5th metatarsal

using a scalpel. A segment of bone was exposed

and excised from the foot and sent to pathology

for diagnostic evaluation. Utilizing 3 liters of

sterile, normal saline, post lavage of the wound

was performed. Iodoform packing was placed

over the wound with a dry sterile dressing

consisting of 4x4’s and cling.”

Always Document:

Document location, laterality, size and depth of wound.

Define if the procedure is excisional or non-excisional.

Must document the type of instrument used to remove any tissue.

Type and amount of tissue must be documented.

Example: Skin, Subcutaneous, muscle or bone.

If no surgical instrument was used (non-excisional), then clearly

describe how the wound was debrided and what specific tools

were used.

Example: Gauze, lavage, brush or pulse, etc.

DebridementDebridement

Complication

“While attempting to locate the left

fallopian tube, a segment of the mesosalpinx

was grasped resulting in a laceration and

bleeding. In order to repair the defect, the

infraumbilical skin incision was extended

bilaterally by 4 cm to allow adequate

visualization. It was necessary to perform a

partial salpingectomy to control the

bleeding. An estimated blood loss of 400 ml

occurred as a result of the complication.”

Post-op Diagnosis:

Accidental laceration of left mesosalpinx

repair with left partial salpingectomy.

Intended, Unavoidable Event

“Inspection of the left adnexa found dense

adhesions of the tube to the mesosalpinx

and left uterine horn. Laceration of vessels in

the underlying mesosalpinx was unavoidable

in order to free the left fallopian tube. As a

result, it was necessary to perform a partial

salpingectomy on the left to control the

bleeding and to complete the sterilization

procedure.”

Post-op Diagnosis:

Left partial salpingectomy due to left

adnexal adhesions.

Not Everything is a Complication!

Complications should be documented if an unexpected event

occurred that required additional treatment to the patient.

Complications should be linked to a diagnosis.

Punctures and lacerations that are unavoidable or inherent

to completion of the intended procedure is not a

complication. Documentation must include the medical

decision making and characterize the event as intentional,

unavoidable or inherent to the procedure.

Complications and Unexpected EventsComplications and Unexpected Events

Intent

Approach

Describe your plan

and what you are

going to do to

specific body parts.

Describe how you

reached the site of

the procedure.

Open

Percutaneous

Percutaneous Endoscopic

Via natural or artificial

opening


opening endoscopic

“We have discussed

with the patient the

removal of her

bladder and the

creation of an

ileoconduit.”

“We sharply

dissected down to the

fascia and the fascia

was then sharply

incised and opened

up.”

Body Parts

Devices

All body parts that are

removed

Laterality

The specific body parts that

are anastomosed

How much of each specimen is

removed.


Body parts connected to the

device.

Intent of the device.

Brand name or device

descriptors.

Placed for the 1st time,

removed or replaced.

Esophagus– Upper, Middle

or Lower

Ascending, Transverse,

Descending or Sigmoid

Stomach or Stomach,

Pylorus

Omentum–

Greater or Lesser

Autologous,

Nonautologous

or Synthetic

Substitute

Drainage

Device

Feeding Device

Intraluminal

Extraluminal

Radioactive

Element

Monitoring

Device

Infusion Device

Artificial

Sphincter

Stimulator

Lead

“We then took out a circle of skin and

subcutaneous fat in the right lower

quadrant. A cruciate incision was

made in the anterior rectus sheath,

and the rectus muscle and posterior

layers were spread apart bluntly. This

was dilated up to three fingers in

width. The ileum about 15 cm

proximal to the ileocecal valve was

brought up here and later matured to

the skin.”

“A 5 French feeding tube

was passed through the

proximal pouch, across

the anastomosis and

into the distal

esophagus until

resistance was met.”

Colon ProceduresColon Procedures

Intent

Approach

Describe your plan

and what you are

going to do to


Describe how you

reached the site of

the procedure.

Open

Percutaneous



opening


opening endoscopic

“We recommended

prompt surgical

exploration with

possible right

hemicolectomy.”

“We inserted a GelPort

and established

pneumoperitoneum after

under direct palpation,

inserting a 12mm port in

the left upper quadrant.”

Body Parts


removed

Laterality


are anastomosed

How much of each specimen

is removed.


Right or Left

Hepatic Flexure

Ascending Colon

Descending Colon

Transverse Colon

Sigmoid Colon

Anus

Rectum

“We thus mobilized the entire

right colon and performed a

right hemicolectomy. All of the

cecum, ascending colon,

hepatic flexure, and a small

portion of transverse colon

were removed off the table

and sent to pathology.”

Colectomy ProceduresColectomy Procedures

Intent

Approach

Describe your plan

and what you are

going to do to


Describe how you

reached the site of

the procedure.

Open


Laparoscopic converted to

open


opening


opening endoscopic

“Based on the

findings, it was

recommended to

undergo a

laparoscopic

appendectomy.”

“A 5mm port was placed

through the sheath.

Laparoscope was

introduced.”

“It was decided at this time

that we needed to convert

our laparoscopic procedure

to open.”

Body Parts


removed

Laterality

The specific body parts that are

anastomosed


removed.


Appendix

Omentum–

Greater or Lesser

“The appendix was removed in

its entirety.

“The enlarged appendix was

encased in the greater

omentum and we therefore

had to remove some of the

greater omentum in order to

remove the appendix.”

AppendectomyAppendectomy

Intent

Approach

Describe your plan

and what you are

going to do to


Describe how you

reached the site of

the procedure.

Open

Percutaneous


Laparoscopic converted to

open


opening


opening endoscopic

“She was placed on

antibiotics and felt to

be in need of an

urgently-performed

laparoscopic

cholecystectomy.”

“I felt the best course of

action for a safe

cholecystectomy was to

convert to open. We

then performed a right

upper quadrant

incision.”

Body Parts


removed

Laterality


are anastomosed


removed.


Gallbladder

Common Bile Duct

Cystic Duct

Omentum–

Greater or Lesser

“The gallbladder was

removed in its entirety

along with a portion of

the common bile duct,

placed in an Endocatch

bag and removed from

the peritoneal cavity.”

CholecystectomyCholecystectomy

Intent

Approach

Describe your plan

and what you are

going to do to


Describe how you

reached the site of

the procedure.

Open

Percutaneous

Percutaneous

Endoscopic

Laparoscopic

converted to open

“We discussed with

patient and wife about

the risks, benefits and

they agreed to

proceed with the

splenectomy.”

“We inserted the 10mm 30

degree lens. We proceeded

to insert after giving local

anesthetic under direct

visualization, four

additional 12mm ports

along the subcostal line.”

Body Parts


removed

Laterality


are anastomosed


removed.


Spleen “We then removed

the spleen in its

entirety.”

SplenectomySplenectomy

Intent

Approach

Document your plan and

what you are going to do to


Document if this procedure

is for diagnostic evaluation.

Described how you

reached the site of

the procedure.

Open

Percutaneous



opening


opening endoscopic

“Patient’s CT revealed a

right upper lobe lung

mass suspicious for

cancer, we elected to

biopsy and performed

transbronchial lung

biopsies.”

“We marked out a posterior

lateral thoracotomy

incision and made this with

a knife. We extended it

down to the latissimus

using the Bovie cautery. We

came through the

latissimus muscle.”

Body Parts


removed

Laterality

The specific body parts that are

anastomosed


removed.


*List every single

body part that is

removed from the

body. *

“We then transected the

entire left lower lung lobe

and passed the specimen

off. We then also removed

the entire chain of the left

internal mammary

lymphatic.”

Devices if Applicable

Body parts connected to

the device.



descriptors.



Therapeutic Substances

Thrombolytic

Radioactive substances

Destructive agents

Antineoplastic

Anti-infective

Anesthetics

Analgesics

MalignancyMalignancy

Intent

Approach

Describe your plan

and what you are

going to do to


“We then proceeded

to perform a

tracheostomy.”

Describe how you

reached the site of

the procedure.

Open

Percutaneous

Percutaneous

Endoscopic

“A cricopharyngeal

myotomy was

performed, cutting along

the cricopharyngeal

muscle down to the

esophageal mucosa.”

Body Parts

Devices

Clearly describe the

placement of the

tracheostomy tube.

Trachea

Esophagus

Body parts connected to the

device.



descriptors.



Tracheostomy

device

“A 5 cuffed

endotracheal tube was

then placed into the

trachea with

confirmation of CO2

return.”

“The tracheostomy

tube was removed

and a new six cuffed

endotracheal tube was

placed within the

tracheostomy site.”

TracheostomyTracheostomy

Intent

Approach

Describe your plan

and what you are

going to do to


Describe how you

reached the site of

the procedure.

Open

Percutaneous



opening


opening endoscopic

External

“He elected to

proceed to the

operating room for

repair of the

right femoral

artery.”

“An incision was

made over the

palpable pulse and

thrill in the left groin

site.”

Body Parts

Devices

Document the exact

anatomical

location(s) of the

procedure.

Body parts connected to

the device.



descriptors.



Autologous Tissue

Nonautologous Tissue

Synthetic Substitute

*Anatomical location of

where autologous tissue

was harvested must be

documented.*

Left or Right

Depth of Tissue–

Skin, Subcutaneous,

Muscle or Bone

Distal or Proximal

Upper or Lower

“We took 6-0 Prolene

sutures; we trimmed up the

edges of both sides of this

large left femoral vessel to

the common left femoral

artery and then primarily

repaired it with a running

6-0 Prolene suture.”

“We harvested the strips of

partial thickness of skin from

the left thigh and meshed them

in a 3 to 1 level with the

Brennan mesher. We then

secured them to the

surrounding skin of the

abdominal wall with staples

and loosely to each other.”

RepairsRepairs

DispositionDisposition

Proper disposition of a patient at the end of a procedure

should be stated as follows

“Transferred (to specific unit) for post operative

monitoring.”

Direct all surgical documentation questions or concerns to

Clinical Documentation Improvement

Gwen Regenwether, RN Ext: 22747

Cheree Lueck, RN Ext: 22795

Dr. Norma Stiglich Ext: 22776

Contact InformationContact Information

OPERATIVEREPORTFORMAT

DISCHARGE/INTERIM/SHORTSTAYSUMMARYFORMAT

Dictatingphysicianname&# 1 Dictatingphysicianname,#,andteamname

Ptname,MRN#,andFIN# 2 Fullattendingname

Dateofsurgery 3 Ptname,MRN#,andFIN#

AttendingMDname 4Admissionanddischargedates‐Identify discharge status: Home, home with home health, correctional care, or SNF

AdditionalMDs’names 5ALLactivelymanageddiagnoses,prioritized(doNOTdesignateasprincipal/secondary)‐Link diagnoses, specify, use stages of illness and acute/chronic where applicable, identify laterality

PreopDxs 6 Comorbiditiesnotactivelymanaged

PostopDxs 7 ALLinvasiveprocedures,excludingradiography

Specimenssenttopathology‐Must specify specimens for diagnosis, and if it was the complete body part

or only partial

8BriefH&P:1–3sentencessummarizinginitialpresentation,thendictate,“SeeinitialH&Pfordetails”

Estimatedbloodloss 9

Concisehospitalcoursebyproblem.1stlineofhospitalcourseshouldidentify:‐Why did the pt require inpatient vs. obs care?

‐What was the risk if pt didn’t get this level of care?

‐What were the main objectives of admission (i.e., goals for discharge)?

Anesthesia 10 DoNOTlistmeds;dictate,“Seemedicationreconciliationform”

Operativeindications/intentofsurgery 11 Medicationchanges,i.e.,newmeds,DC’dmeds,dosechanges

Procedure(s)performed 12

Disposition/follow‐upplan‐Condition of pt at time of discharge

‐Follow‐up appts and time frame

‐Important items for F/U at 1st appt, pending labs and studies

Procedurenarrative 13 Interimsummariesshouldinclude#1–6 only

Device(s)implanted 14 Copiestonon‐DHprovider,ifapplicable.Mustincludefax#inCC.Explaindeviationsfromplannedprocedure‐What was done?

‐Was it avoidable?

‐Was standard treatment altered?

15

Alwaysspecifybodypartsandlaterality 16ContactClinicalDocumentationIntegrityforquestionsregardingproperdocumentation.

The discharge summary is a vital part of the chart summarizing care. This is the key to clarifying why the patient merited the level of care they received.

Documents

“Did of Out?” · $10.6M $3.9M $1.6M $357,000 $160,000 $1.7M $204,000 $470,000 $0 $5 $10 $15 $20 $25 $30 $35 $40 $45 GSR Ortho NSR POD MAX GYN GU ENT Millions Claims/qtr for each