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TriAssess® Premier Software now includes 7 more patient education documents in Spanish continuing to support Joint Commission National Patient Safety Goal 13
Continuing to assist you with your patient education, Wound Care Strategies is pleased to offer 7 additional patient education documents, in Spanish, housed within TriAssess® Premier Software. We will continue to design and develop the patient education material necessary for your compliance with accreditation and regulatory standards.
Patient education and compliance are the cornerstones to successful wound and skin care. The educational needs of your patient should be evaluated on an individual basis beginning with the non-judgmental assessment of your patient’s current knowledge base relevant to the plan of care determined. Validating the impact of the education by measuring retention of the material is paramount for a successful plan.
Proper patient education enhances patient safety, quality, and cost-effective outcomes. Ensuring that your patients completely understand the type of care your patients receive you will:
- Improve health outcomes
- Increase focus on patient safety
- Facilitate patient-centered care
- Reduce length-of-stay
- Reduce readmission rates
- Improve the bottom line.
Joint Commission Patient Safety Goal 13 reviewed::
According to Joint Commission National Patient Safety Goal 13:
Goal 13
Encourage [patient]s’ active involvement in their own care as a [patient] safety strategy.
NPSG.13.01.01
- Identify the ways in which the [patient] and his or her family can report concerns about safety and encourage them to do so.
- Communication with the [patient] and family about all aspects of care, treatment, and services is an important characteristic of a culture of safety. When the [patient] knows what to expect, he or she is more aware of possible errors and choices. The [patient] can also be an important source of information about potential adverse events and hazardous conditions.
Rationale for NPSG.13.01.01
Elements of Performance for NPSG.13.01.01
- The patient and family are educated on available reporting methods for concerns related to care, treatment, and services and patient safety issues.
Additionally, please find a new Joint Commission document for your review entitled Hospitals, Language, and Culture: The Snapshot of a Nation is located here
Physician billing: Referring to Prior Exams
Excerpted from DecisionHealth e-news
Question: "I have a physician who wants to refer back to prior exams to get credit. I have instructed him not to do that. Now, I am looking for specific instructions for exam documentation. Any ideas?"
Answer: "You are correct - the physician can't refer back to past exam elements. But unfortunately we can't point to a black-and-white sentence that says so. Instead, we must rely on underlying principles to make the point. The underlying principle here: Only in the case of the Review of Systems (ROS) and Past, Family and Social History (PFSH) are providers allowed to refer to prior documentation.
The E/M documentation guidelines (both ‘95 and ‘97) indicate one situation - and one situation only - in which a physician can avoid documenting the information he/she gathers during an encounter by referring to documentation gathered at a prior visit. This explicit permission applies only to ROS and to PFSH - not to exam elements."
PRACTICE POINTS: Monitoring Laboratory Values: Lymphocytes, Blood Urea Nitrogen, Creatinine, and Lipoproteins
Each month, I write a column entitled Practice Points in Advances in Skin & Wound Care: The Journal for Prevention and Healing. Over the last few columns, my focus has been on lab values. I would like to share the April column with you and your team - Monitoring Laboratory Values: Lymphocytes, Blood Urea Nitrogen, Creatinine, and Lipoproteins.
You may access the article through the following link
http://www.nursingcenter.com/pdf.asp?AID=853673 .
WCS Note:
Laboratory values are helpful in assessing and monitoring any chronic underlying medical conditions as well as the patient’s nutritional status. These values should be evaluated upon the first patient encounter to establish a baseline for care. In addition, if healing isn’t occurring as expected, these values can be tracked regularly to ensure that local and systemic factors aren’t contributing to poor healing. Important parameters to evaluate include protein levels, complete blood count, erythrocyte sedimentation rate, liver function tests, glucose and iron levels, total lymphocyte count, blood urea nitrogen and creatinine levels, lipoprotein levels, vitamin and mineral levels, and urinalysis. Even if only one deterrent is present, healing can’t occur.
CMS announces new publication and FAQs for ICD-10 mappings
CMS announced on April 6 that a new Medicare Learning Network publication, General Equivalence Mappings - ICD-9-CM To and From ICD-10-CM and ICD-10-PCS Fact Sheet (March 2009),
is available as a fact sheet here
The publication provides information about the mappings, which enable conversion of ICD-9-CM codes to ICD-10 and the conversion of ICD-10 codes back to ICD-9-CM. The information also appears in CMS FAQ 9661
Click here to view
World Privacy Forum publishes HIPAA guide for patients
Excerpted from HIM Connection
The World Privacy Forum announced its publication of a comprehensive HIPAA privacy guide written with patients in mind titled Patient’s Guide to HIPAA: How to Use the Law to Guard Your Health Privacy, according to a March 31 press release. To access this document, link to http://www.worldprivacyforum.org/hipaa/index.html
"This guide is not just a retread of what HIPAA is and does," said Pam Dixon, executive director of the World Privacy Forum in the press release. "Our guide gives patients practical details and strategies on how they can use the law to protect their privacy and navigate the medical system. Best of all, it is easy to use."
The guide includes 65 frequently asked questions that are divided into the following four sections:
- Introduction and purpose
- Learning about HIPAA
- The seven basic patient rights
- What you should know about uses and disclosures
U.S. hospitals lack EMRs
Excerpted from HIM Connection
Only 1.5% of U.S. hospitals have a comprehensive electronic records systems in all clinical units, according to a new study, “Use of Electronic Health Records in U.S. Hospitals,” published in the March 25 issue of The New England Journal of Medicine – link http://content.nejm.org/cgi/content/full/NEJMsa0900592 .
Another 7.6% use a basic system on at least one clinical unit. Only 17% of hospitals implemented computerized provider order entry systems for medications.
"The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic records systems in U.S. hospitals," stated the study.
The American Recovery and Reinvestment Act of 2009 dedicates $19 billion to implementing health information technology.
WCS Note:
Kudos to your hospital with an EMR!
State law forces MRSA screening
Excerpted from Infection Control Monitor
A proposed law that forces hospitals in Washington to screen high-risk patients for MRSA, passed through the state Senate unanimously on Monday.
The bill now moves to the governor’s office for a signature that will make it a law, according to the Seattle Times. The law would require hospitals to implement a screening policy by January 1, 2010. Adult or pediatric intensive care patients would require screening within the first 24 hours.
Hospitals would also need to disclose treatment and prevention measures, including isolation policies, to patients infected with MRSA.
WCS Note:
This article relates only to the state of Washington (at this time).
Document E/M services to ensure appropriate physician code level assignment
Excerpted from Just Coding
Coding for evaluation and management (E/M) services is no walk in the park for coders. They must rely on physician documentation to determine the level of service for each of the critical components. Documentation also drives what code they ultimately assign for each encounter.
E/M services include several complex categories and different service components within each category. This presents compliance risks coders need to watch for when assigning codes. When selecting an E/M code, coders must first determine in what category the visit falls. Is the patient new or established? Is this a routine outpatient office visit or a consultation?
To read this entire article, click here
WCS Note:
TriAssess Premier Software (TPS) is built on the Medicare Guidelines and the entire medical record supports both the facility and physician documentation. TPS chronologically documents the care of the patient and provides the documentor the ability to document pertinent facts, findings, and observations about the patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
The record supports:
- Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
- Assessment, clinical impression, or diagnosis; and the
- Medical plan of care;
which are all necessary elements to support the Physician E/M and the facility visit.
TPS ties the clinical, functional and financial information for the patient’s visit and proves the work performed much faster. This EMR, TPS, tracks the physician work and his assessment data, as well as the clinician’s time and work performed.
Healthcare Common Procedure Coding System (HCPCS) Update
The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the HCPCS web page at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/02_HCPCS_Quarterly_Update.asp. Changes are effective on the date indicated on the update.
WCS Note:
When you review the changes for the second quarter, you will note 2 new skin substitute codes will be added July 1, 2009 to the HCPCS Codes. TPS users will find this code automatically updated in their CPT/HCPCS database on July 1, 2009.
| HCPCS Code | Short Description | Long Description | Effective Date |
| Q4115 | Alloskin skin sub | Skin substitute, Alloskin, per square centimeter | 7/1/2009 |
| Q4116 | Alloderm skin sub | Skin substitute, Alloderm, per square centimeter | 7/1/2009 |
PRACTICE POINTS: Monitoring Laboratory Values: Glucose, Hemoglobin, Hematocrit, and Iron
Each month, I write a column entitled Practice Points in Advances in Skin & Wound Care: The Journal for Prevention and Healing. Over the last few columns, my focus has been on lab values. I would like to share the March column with you and your team - Monitoring Laboratory Values: Glucose, Hemoglobin, Hematocrit, and Iron.
You may access the article here
WCS Note:
Clinicians can reduce the chances of misdiagnosing a wound by making use of the following tools:
* The medical record which provides a means for accurately describing the wound's characteristics at each patient visit
* Risk assessment tools, which ensure systematic evaluation of individual risk factors
* Nutritional risk assessment tools, which assist the clinician in understanding the strategies necessary to identify levels of nutritional risk
* Manual screening tools, which include the ankle-brachial index, lower leg and foot assessments, palpation of pulses and Doppler ultrasound, segmental blood pressures, Semmes-Weinstein monofilament testing, transcutaneous oxygen pressure (TcPO2), and vibration perception threshold assessment.
* Other diagnostic tests, such as laboratory values, bacterial swab cultures, tissue cultures, skin biopsies, radiologic studies, and vascular studies, should also be taken into consideration when evaluating a patient at risk.
The documentor is able to capture risk assessments, nutritional risk, manual screening tools results and diagnostic test results with the electronic medical record, TriAssess Premier Software.
TriAssess® Premier Software will be exhibited at SAWC
Wound Care Strategies will be exhibiting TriAssess Premier Software at SAWC in April 26-29, 2009. I am extending you a personal invitation to visit with us at booth 835. Please stop by, at your convenience, and say hello!
Growth reported in Wound Care Market despite economic climate
There are many markets that will be impacted by the current economic climate, but the treatment of wounds is not one of them, according to a healthcare market research publisher's latest report on the wound care industry.
To read about this information
Click Here
National Patient Safety Awareness information from CMS
The Centers for Medicare & Medicaid Services (CMS) reminds beneficiaries and health care professionals what patients and their local healthcare providers can do to improve the safety of care. CMS is also working to make health care safer through its Quality Improvement Organization (QIO) Program.
What is CMS doing to make health care safer?
In addition to working with consumers on quality of care problems, QIOs are working nationwide with select hospitals and nursing homes to improve patient safety by:
- Improving surgical safety/infection rates.
- Reducing rates of certain infections in hospitals.
- Intensively working with "nursing homes in need."
- Improving care for patients with heart failure.
- Preventing pressure ulcers (or "bed sores") in patients from nursing homes and hospitals.
- Eliminating physical restraints in nursing homes.
- Combating drug-drug interactions and potentially inappropriate medication errors.
Health care professionals can learn more about how QIOs are making care safer
click here
WCS Note:
TriAssess® Premier Software and the Admission Assessment ManagerTM Inpatient Software can collect the necessary data to report surgical site infections, pressure ulcers, organisms, and UTIs. Users can access this information through TPS suite of reports.
Update on Final Rules Regarding ICD-10 Code Sets and Standards Governing Electronic Transactions
On January 15, the U.S. Department of Health and Human Services released two final rules that will facilitate the United States’ ongoing transition to an electronic health care environment through adoption of an updated set of diagnosis and procedure codes and updated standards for electronic health care and pharmacy transactions.
In accordance with the White House Chief of Staff’s memorandum of January 20, 2009 entitled "Regulatory Review," a determination has been made that the effective date will not be extended and the comment period will not be reopened for either of these rules.
The first rule finalizes new code sets to be used for reporting diagnoses and procedures on health care transactions. This final rule replaces the ICD-9-CM code sets, developed nearly 30 years ago, with greatly expanded ICD-10 code sets. The second final rule adopts updated versions of the standards governing electronic transactions under the authority of the Health Insurance Portability and Accountability Act of 1996. The updated versions replace the current standards and will promote greater use of electronic transactions. In response to public comments suggesting that more time would be needed for effective industry implementation, the final rules include later compliance dates. More specifically, the final rules provide compliance dates of Jan. 1, 2012, for the transaction standards and Oct. 1, 2013, for the ICD-10 code set.
CMS and AHRQ partner to review negative pressure wound therapy (NPWT) devices
The Centers for Medicare and Medicaid Services have partnered with the Agency for Healthcare Research and Quality (AHRQ) to commission a review of Negative Pressure Wound Therapy (NPWT) devices. The purpose of this review is to provide information to the Centers for Medicare & Medicaid Services (CMS) for consideration in Healthcare Common Procedure Coding System (HCPCS) coding decisions. Section 154(c) (3) of the Medicare Improvements for Patient and Providers Act of 2008 (MIPPA) calls for the Secretary of Health and Human Services to perform an evaluation of the HCPCS codes for NPWT devices.
To read about this information, click here
Hospitals to report nine-digit ZIP codes of outpatient service locations for certain services
Excerpted from APC Monitor
On February 13, CMS issued a clarification for the calculation of payment amounts for services paid to hospitals on the basis of the Medicare Physician Fee Schedule (MPFS), such as physical therapy, occupational therapy, speech language pathology, and mammograms. The instruction requires providers to report the ZIP code of outpatient service facility locations for off-site outpatient facilities.
CMS explains that the change responds to changes in how hospitals provide outpatient services. Effective July 6, CMS will use the facility location's nine-digit ZIP code to calculate the appropriate local MPFS payment.
The transmittal
can be found here.
Revised Hospital Outpatient Prospective Payment System Fact Sheet Available for Download
The Hospital Outpatient Prospective Payment System Fact Sheet (January 2009), which provides general information about the Hospital Outpatient Prospective Payment System, ambulatory payment classifications, and how payment rates are set, is available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network
here
Revised Medicare Fraud & Abuse Fact Sheet is Now Available
Revised January 2009, the Medicare Fraud & Abuse Fact Sheet is now available at, http://www.cms.hhs.gov/MLNProducts/downloads/Fraud_and_Abuse.pdf, on the Medicare Learning Network (MLN). The Centers for Medicare & Medicaid Services (CMS) works with other government agencies and law enforcement organizations to protect the Medicare program from fraud and abuse.
WCS Note:
Fraud and Abuse and Compliance go hand-in-hand. Please see the following question and answer that appeared in APCs Weekly Monitor (December 2008) and found on Wound Care Strategies Newswire at http://www.woundcarestrategies.com/news.php
Q. Can you update me on any changes regarding the E/M CPT codes that hospitals must use for 2009 OPPS?
A. For 2009, hospitals must continue to use their internally developed guidelines for ED and clinic E/M visits, and adhere to the 11 principles developed in 2008 by CMS. Review the 11 principles with your facility E/M criteria team to maintain the circle of compliance for this reporting requirement.
The 11 principles follow. The coding guidelines should:
- Follow the intent of the CPT code descriptor; the guidelines reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
- Relate to hospital facility resources, not to physician resources.
- Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
- Meet HIPAA requirements.
- Only require documentation that is clinically necessary for patient care.
- Not facilitate upcoding or gaming.
- Be written or recorded, well-documented, and provide the basis for selection of a specific code.
- Be applied consistently to all patients in the clinic or ED to which they apply.
- Not change frequently.
- Be readily available for FI (or, if applicable, MAC) review.
- Result in coding decisions that other hospital staff or outside sources can verify.
CMS has changed the definition for distinguishing between new and established facility E/M levels for 2009 from whether the patient has had a medical record number created within the past three years to whether the patient was registered as an inpatient or outpatient within the past three years.
Wound Care Strategies and APCs Weekly Monitor recommends a dedicated plan for performing detailed audits in all areas that report E/M levels. This will help ensure consistency, accuracy, and incorporation of the clinic definition that distinguished between new and established E/M levels. Monitoring modifier -25 (significant, separately identifiable E/M service by same physician on the same day of the procedure or other service), will help identify potential recovery audit contractor vulnerabilities. This is especially true for clinics which perform scheduled procedures along with medical visits on the same day.
2009 Facility E/M Levels under OPPS / TriAssess Premier Software Compliance
CMS and three new National Coverage Determinations (NCDs) on error prevention
- Wrong surgical or other invasive procedures performed on a patient;
- Surgical or other invasive procedures performed on the wrong body part; and
- Surgical or other invasive procedures performed on the wrong patient.
While you are provided with direct access to the memo and supporting documentation, pay special attention to the definition of "surgical" that appears in these NCDs:
Surgical and other invasive procedures are defined as operative procedures in which skin or mucous membranes and connective tissue are incised or an instrument is introduced through a natural body orifice. Invasive procedures include a range of procedures from minimally invasive dermatological procedures (biopsy, excision, and deep cryotherapy for malignant lesions) to extensive multi-organ transplantation. They include all procedures described by the codes in the surgery section of the Current Procedural Terminology (CPT) and other invasive procedures such as percutaneous transluminal angioplasty and cardiac catheterization. They include minimally invasive procedures involving biopsies or placement of probes or catheters requiring the entry into a body cavity through a needle or trocar. [Emphasis added.]
One important aspect related to the surgical procedure is the "time out" . The Joint Commission approved the "Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person SurgeryTM", which was designed to help prevent such errors.
WCS Note:
TriAssess Premier Software supports the time out procedure within its Procedure Screen.
CMS ISSUES THREE NATIONAL COVERAGE DETERMINATIONS TO PROTECT PATIENTS FROM PREVENTABLE SURGICAL ERRORS
Payers may not reimburse for procedures or services within physician's global period
Excerpted from APC Monitor
When we work side-by-side with the Wound and Hyperbaric Departments implementing the clinical and operational processes supported by TriAssess Premier Software, we often talk about the physician global period. The following is a question and answer excerpt from the APC Monitor by HCPro.
Q. We are having a problem with facility E/M billing during the postoperative global period at our facility. I found the following ruling regarding facility postoperative care during the physician surgical global period in the Federal Register (18448 Federal Register / Vol. 65, No. 68 / April 7, 2000 / Rules and Regulations):
For now, hospitals are to bill follow-up care, such as suture removal, using an appropriate medical visit code. We did not propose, nor have we included in this final rule with comment period, provision for a global period for hospital outpatient services analogous to the global period affecting payments for professional services made under the Medicare physician fee schedule.
Although this information is from April 2000, I have searched but have not found an update to this rule. Is this rule still correct or have there been any updates or changes since 2000?
A. This information is still correct. CMS bases OPPS reimbursement on individual services for individual dates of service, and the global period is not applicable. However, consider what the quoted guidance says about providing a service in a hospital setting within the physician’s surgical global period.
Many payers will not reimburse a facility for a procedure or service that is part of the physician’s global service period. Because this is a payer-specific situation, you should check with your FI or MAC, or other payers, about the reasons for the difficulties you are experiencing.
WCS Note:
It is imperative that each facility discuss these issues with your billing and coding departments so that proper billing occurs at each visit. As always, keep abreast of your FIs LCDs in the outpatient departments!
Cigna bulletin boosts importance of good physician documentation
Excerpted from APC Monitor
A December 2008 bulletin from CMS carrier Cigna should add an extra impetus for reluctant physicians unwilling to document to a higher degree of specificity.
Documentation of the three elements of E/M "patient history, physician medical decision making, and the exam itself" is separate and distinct from documentation of medical necessity, according to the bulletin. In other words, carriers will deny physician payments for services, such as initial and subsequent inpatient visits, if the services aren’t supported by good documentation demonstrating the medical necessity of those visits.
WCS Note:
TriAssess Premier Software (TPS) is built on the Medicare Guidelines and the entire medical record supports both the facility and physician documentation. TPS chronologically documents the care of the patient and provides the documentor the ability to document pertinent facts, findings, and observations about the patient’s health history including past and present illnesses, examinations, tests, treatments, and outcomes.
The record supports:
Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
Assessment, clinical impression, or diagnosis; and the
Medical plan of care;
which are all necessary elements to support the Physician E/M and the facility visit.
This electronic medical record (EMR) ties the clinical, functional and financial information for the patient’s visit and proves the work performed much faster. This EMR, TPS, tracks the physician work and his assessment data, as well as the clinician’s time and work performed.
TPS also has the ability to track the clinical activities and outcomes, tie time as a function of the program to determine the cost of care, integrate pathways and algorithms to assist in clinical and regulatory compliance, and benchmark the work performed.
Evaluating the effectiveness of the plan of care and the status of the skin and wound requires documenting assessments and interventions. Skin and wound care documentation can combine a variety of information-gathering tools reflecting the wound’s status across the healing continuum. When assessing the patient with a skin or wound condition, the details of the documentation within TPS should reflect the following data points:
- Chief complaint;
- History of Present Illness
- Past Medical, Family and Social History;
- Review of Systems;
- Physical Assessment;
- Risk Assessment Tools;
- Manual Assessments Tools;
- Skin and Wound Assessment Tools;
- Procedures;
- Ordering Supplies and Tests;
- Patient Education Details;
- Plan of Care;
- Discharge Plan.
These components, comprising the medical record, provide the platform for documentation and support the continuity of care.
Mark your calendar: ICD-10 is effective October 1, 2013
On January 15, the Department of Health and Human Services (HHS) announced the final rule to replace the ICD-9-CM code sets now used to report healthcare diagnoses and inpatient procedures with the more advanced ICD-10 code set currently used in other nations. The final rule will implement the ICD-10 code set October 1, 2013, two years later than HHS initially proposed.
WCS Note:
Wound Care Strategies updates TriAssess Premier Software (TPS) updated the ICD9 and CPT Codes annually. Wound Care Strategies will continue to move forward and integrate the ICD-10 code set when necessary.
Hot spots for auditing
In a recent e-news bulletin by a coding agency, the following information was provided:
"Earning of an E&M when done with a procedure - especially with your hospital based clinics - IV infusion, chemo, wound; Ensure the documentation shows the clinical reasons why the patient cannot assume self care - especially in the areas of wound care over an extended period of time."
WCS Note:
TriAssess Premier Software provides the department with the documentation necessary to validate the patient’s visit. Just a reminder, it is important to capture the reason for the visit, having it thread to the patient’s chief complaint and condition summary. The proper documentation provides guidance for appropriate treatment decisions, evaluation of the healing process, support for reimbursement claims, and a defense for litigation. Once established, the documentation system should become the framework of clinical practice for all wound-care team members.
Inside the program: Involve patients in their plan of care
Excerpted from HCPro's Weekly Update on the ANCC Magnet Recognition Program®
Patients today are very knowledgeable and want a voice in what treatment approaches will be implemented, which medications they will take, and where they will be hospitalized.
A shared governance model is an integrating structure that brings together nurses, physicians, interdisciplinary team members, patients, and family members. As a process structure of partnership between staff nurses and patients, a shared governance model provides the vehicle for improved communication, greater responsibility and accountability, and a way of coordinating, integrating, and facilitating care at the point of service.
Involve patients in their plan of care by:
- Asking patients for their questions, concerns, or ideas
- Asking the patient what their physician said and listening to the patients report instead of telling the patient what the physician wrote in the chart
- Inviting patients to attend the interdisciplinary team meetings when the team members are discussing that patient’s care
WCS Note:
Remember to utilize the Patient Instructions Sheet/Report at the end of each patient visit. It is important to document the work performed to support your visit with the patient. Also, remember to print out the companion patient education (in English and/or Spanish) or disease management document with the Patient Instruction Sheet.
Surgical checklist reduces deaths
Excerpted from Infection Control Weekly Monitor
A 19-item safety checklist used by surgical teams does what it is intended: reduces complications and deaths, according to a new study. The checklist, developed by the World Health Organization (WHO) in 2008, includes steps such as having nursing staff confirm all equipment is sterilized and requiring that team members confirm the patient has received antibiotics ahead of the surgery, if called for, to reduce the risks of infection.
Researchers reported in the January 14 online edition of The New England Journal of Medicine that the safety checklist, designed to improve surgical team communication and consistency of care, was effective. A year after eight hospitals in various countries adopted the checklist as part of the WHO’s Safe Surgery Saves Lives program, the average patient death rate fell more than 40 percent and the rate of complications fell by about a third, researchers found.
To read more about the study, click here
WCS Note:
While this article focuses on the operating room, you will find the checklist also integrates the importance of "time out" prior to the procedure.
2009 Facility E/M Levels under OPPS / TriAssess Premier Software Compliance
The following question and answer appeared in APCs Weekly Monitor (December 2008).
Q. Can you update me on any changes regarding the E/M CPT codes that hospitals must use for 2009 OPPS?
A. For 2009, hospitals must continue to use their internally developed guidelines for ED and clinic E/M visits, and adhere to the 11 principles developed in 2008 by CMS. Review the 11 principles with your facility E/M criteria team to maintain the circle of compliance for this reporting requirement.
The 11 principles follow. The coding guidelines should:
1. Follow the intent of the CPT code descriptor; the guidelines reasonably relate the intensity of hospital resources to the different levels of effort represented by the code.
2. Relate to hospital facility resources, not to physician resources.
3. Be clear to facilitate accurate payments and be usable for compliance purposes and audits.
4. Meet HIPAA requirements.
5. Only require documentation that is clinically necessary for patient care.
6. Not facilitate upcoding or gaming.
7. Be written or recorded, well-documented, and provide the basis for selection of a specific code.
8. Be applied consistently to all patients in the clinic or ED to which they apply.
9. Not change frequently.
10. Be readily available for FI (or, if applicable, MAC) review.
11. Result in coding decisions that other hospital staff or outside sources can verify.
CMS has changed the definition for distinguishing between new and established facility E/M levels for 2009 from whether the patient has had a medical record number created within the past three years to whether the patient was registered as an inpatient or outpatient within the past three years.
Wound Care Strategies and APCs Weekly Monitor recommends a dedicated plan for performing detailed audits in all areas that report E/M levels. This will help ensure consistency, accuracy, and incorporation of the clinic definition that distinguished between new and established E/M levels. Monitoring modifier -25 (significant, separately identifiable E/M service by same physician on the same day of the procedure or other service), will help identify potential recovery audit contractor vulnerabilities. This is especially true for clinics which perform scheduled procedures along with medical visits on the same day.
To that end, please find two articles that may assist you in developing your wound care audit plan
Developing a Wound Care Compliance Program (Part 1)
Developing a Wound Care Compliance Program (Part 2)
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