Codeman: Technical and ProfessionalMar. 10, 2018, 4:24 PM
- This coding is based on the diagnoses that you document in your inpatient notes.
- This coding determines the DRG that is submitted to payors for reimbursement.
- This coding determines how VUMC compares to other Academic Medical Centers and how we are ranked in the annual US News & World Report Hospital Ranking.
- Our Clinical Documentation Specialists (CDC) might query you in eStar InBasket (Clinical Doc Query) for clarity and specificity of your diagnoses. For example, they may ask you about the acuity of heart failure, the cause of anemia, or the type of shock. Please respond to every one of those queries thoughtfully. Even the documentation of diagnoses as simple as hypokalemia and acidosis can have a significant impact on the DRG.
- Your thoughtful responses to these Queries can have a significant impact for VUMC in terms of reimbursement and national reputation.
- Your job here is to document in the record every possible diagnosis that pertains to a given patient.
- This E & M coding involves those pesky Medicare rules for the content of your notes: the History & Physical elements, and, especially, Medical Decision Making.
- This coding is done for inpatient and outpatient notes.
- All of you are already doing the E & M coding of your outpatient notes in eStar.
- Later this year, you will be expected to code your inpatient notes as well. This will not be as hard as you may think. Stick with me and I will teach you how to do it.
- Our professional Coders review your inpatient notes mainly looking for note content and timely note completion. They will contact you through eStar InBasket (VMG Coding Task).