Now that the problems have been identified, recommend steps to improve documentation for reimbursement issues.
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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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