Coding and Documentation

Q: My team and I are responsible for clinical documentation improvement (CDI). We’re considering adding a reconciliation element to our CDI review process next year. In your experience, what’s been the biggest benefit of performing reconciliation on charts?

Q: We are a critical access hospital (CAH). We provide smoking cessation therapy (CPT codes 99406-99407) in our cardiac rehab department. The documentation is done and signed by a respiratory therapist (RT), and we are currently billing this as a professional charge (on a UB-04 with revenue code 0981). My question is, can we bill this on a UB-04 as a facility charge only and still allow our RT or other ancillary staff to perform it?

Reach your destination by planning for revenue integrity success.

Consider the financial impact of CMS’ proposals for outpatient hospital payments.

Review CMS’ proposals in the 2023 Medicare Physician Fee Schedule for changes to facility E/M coding and other coverage and reimbursement updates.

Use this observation code crosswalk to train staff on the pending changes.

Ensure your organization is complying with CMS’ latest requirements for hospital inpatient billing and reimbursement.

Take a fresh look your CDI/coding reconciliation process and apply these tips for improving it.