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Clinical Charting Guidelines per the IPPS Rule and How that Applies to Electronic Documentation
September 30, 2009, 1:00 pm - 2:00 pm CDT
Michael Larson, Deloitte Consulting. As has always been the case, the medical record must substantiate the diagnosis, procedures and services that appear on the claim. With the recent Inpatient Prospective Payment System (IPPS) rule from the Centers for Medicare and Medicaid Services (CMS), the need for accuracy and precision of clinical documentation is expected to increase. This affects how clinicians chart and how the chart is expected to be coded. The expectation has affected what electronic health record (EHR) vendors offer in regards to recommendations for electronic charting. Besides explaining these recommendations, the topic of exception charting with respect to clinical precision is described. Michael provides a review of CMS expectations, the vendor offerings regarding clinical documentation, and how vendor offerings dictate level of documentation and exception charting. Included are examples of how major health institutions handle exception charting and the level of detail developed for online charting.