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Tips to Boost Your Documentation Process: Changes in Physician Certification Effective Jan. 1, 2015

Posted on Wed, Jan 07, 2015
Tips to Boost Your Documentation Process: Changes in Physician Certification Effective Jan. 1, 2015

Good documentation is important for new physicians as well as veteran caregivers. While documenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach.

by: Timothy N. Brundage, M.D., CCDs

Changes in Physician Certification Effective Jan. 1, 2015

An important reminder – as of Jan. 1, 2015, a separate physician certification will no longer be required under CMS guidelines.

CMS has finalized changes to physician certification requirements:
 

  • Physicians will no longer need to provide formal certification for inpatient admission unless the admission is expected to last 20 days or longer, or the case is an outlier
  • Inpatient admission orders will remain a requirement as a condition of payment under Medicare Part A
  • Physicians will need to certify high-cost outlier cases for medical necessity

These changes will make it much more important that documentation reflect medical necessity and how sick admitted patients in order to justify each inpatient admission. These changes are expected to improve hospital efficiency.

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

 

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