If possible, it may be helpful to indicate “Admission Diagnoses” with the diagnoses listed on this admission document while maintaining an up-to-date listing on the Diagnosis List.If the face sheet/admission record must be current, staff should develop a procedure for maintaining this document.In addition to facing criminal sanctions and significant monetary penalties, providers that have failed to adequately ensure the accuracy of their claims and cost report submissions can have their Medicare payments suspended (42 CFR 405.371), be excluded from program participation (42 U. Many facilities utilize a document for the listing of diagnoses, often titled Diagnosis List, that is initiated upon admission.
With the arrival of consolidated billing and the next edition of the coding manuals, it will be even more critical that knowledgeable individuals are performing these coding tasks. If staff who code do not have access to a formal training course, at a minimum, they should attend a comprehensive coding workshop, have current resource materials available, and access to a trained, credentialed HIM consultant/professional for questions and clarification.
The risk areas associated with billing and cost reporting have been among the most frequent subjects of investigations and audits by the OIG. 1320a-7(b)), or, in lieu of exclusion, be required by the OIG to execute a corporate integrity agreement (CIA).” Federal Register/Vol. Health information staff can also opt to code the record on a concurrent basis.
Each code number represents a specific disease or condition for the resident that must be supported by physician documentation.
An inaccurate diagnosis code used to justify services billed could potentially be considered fraudulent if the resident does not have the diagnosis used to justify the services utilized and billed.
Another concurrent process is to assign codes based on the physician order entry into the clinical computer system.
Concurrent coding helps to assure that the medical record and information system have up-to-date information on diagnoses at all times.
As residents may remain in long term care facilities for extended periods of time, the diagnosis listing can become extensive with numerous updates.
If the inclusion of diagnoses is required on the face sheet/ admission record, it may be time consuming and difficult in the limited space to update this information on a concurrent basis.
It is important that all services and supplies represented by the CPT or HCPCS codes be supported by documentation in the medical record regardless of whether it is a Medicare part A claim (where all services are lumped together under one revenue code) or a Medicare part B claim (where each item is line item billed per service and per day).