Description:-

This workshop is devoted to the documentation requirements for observation services. Due consideration is given to distinguishing observation services from inpatient admissions. Physician documentation along with nursing and clinical documentation are included. Payment documentation is distinguished from clinical documentation. Charge capture and proper billing issues are discussed relative to the overall documentation process.  Auditing standards are addressed so that both the documentation and documentation process can be assessed relative to external audits such as the RACs. Special situations such as the Over 2-Midnight Rule and the MOON form are discussed relative to documentation.

• Just What Is Observation?
• How Is Observation Different From an Inpatient Admission?
• Do Patients Understand the Difference?
• How Should A Physician Document To Justify Observation Services?
• Is There A Difference Between Payment Documentation and Clinical Documentation?
• What Should A Physician Document At Discharge From Observation?
• How Can An Observation Log Assist In Justifying Observation?
• How Does The Use of Condition Code 44 Affect the Documentation?
• How Should Nursing Staff and Other Clinical Staff Document To Support Coding and Billing for Observation?
• Why Is It Important To Carefully Track Time and Interrupted Observation?
• What Kind of Policies and Procedures Should Be In Place To Effectively Document, Code and Bill for Observation?
• What is This MOON Form and How Should It Be Handled?
• Why Is Post-Surgical Observation Such An Issue?
• Is Observation Followed By a Procedure a Problem?
• How Do Auditors View Observation Services?
• How Do Private Payers View Observation?

Teleconference/Webinar Objectives:- 

• To discuss the concept of observation and associated services.
• To review how physicians should document to justify observation services.
• To discuss what physicians should document at the time the patient is discharged from observation services.
• To review how documentation must support the coding and billing process.
• To distinguish payment documentation from clinical documentation.
• To understand how observation differs from inpatient admissions.
• To discuss the medical decision making relative to the over 2-midnights rule.
• To appreciate the need to track hours of observation including intervening services.
• To understand how an Observation Log can assist in reviewing documentation and appropriateness of coding and billing.
• To appreciate the need to fastidiously address use of the MOON form.
• To understand the use of standard observation protocols or care paths.
• To appreciate the documentation requirements that will satisfy auditor requirements.
• To appreciate why Medicare is so concerned about post-surgery observation.
• To realize how Medicare reimbursement is affected by a procedure performed after observation.
• To understand how private payers view and use observation services.

Teleconference/Webinar Outline/Agenda:-

• Observation Services
  • Types and Levels of Services
  • Organization and Provision of Observation Services
    
    • Dedicated Units
    • Medical/Surgical Floor Beds
  • Coding, Billing and Payment for Observation
  • Distinguishing Inpatient from Outpatient Observation
  • Physician Supervision
• Documentation for Observation
  • Physician Documentation
    
    • Justifying Observation Services
    • Interim Visits
    • Discharge from Observation Summary
  • Over 2-Midnights Rule
  • Use and Advantages for an Observation Log
  • Nursing and Clinical Documentation
  • Payment Documentation versus Clinical Documentation
  • Care Paths for Observation Services
    • Types of Care Paths
    • Documentation Sufficiency
  • Physician Supervision
• MOON Form
  • Policies and Procedures – Timing, Presenting, Explaining
  • Documentation for Observation vs. Inpatient Admission
  • Signature Requirements
  • Personnel Requirements
• Auditing Observation Services 
  • Developing Audit Guidelines
  • Preparing the Documentation Package for Observation
  • Conducting Mock Audits
• Private Payer Consideration for Observation 
  • Changing Inpatient to Observation
  • Documenting Requests From Private Payers to Change Inpatient to Observation
• Payment for Observation Services 
  • Physician Payment
  • OPPS Payment – Comprehensive APC 8011
  • Private Payer Payment
• Special Considerations
  • RAC Audits
  • Coordination With ER Services
  • Coordination With Inpatient Admissions
• Sources for Further Information

Prerequisites for Participating:-

Knowledge of observation services and the basics of coding, billing and Medicare rules and regulations.

Suggested Attendees:-

Outpatient Nursing Staff, Medical/Surgical Nursing Staff, Nurse Managers, ED Nursing Staff, Utilization Review Personnel, Quality Assurance Personnel, Quality Assurance Personnel, Physicians, Non-Physician Practitioners, Coding Personnel, Billing and Claims Transaction Personnel, Chargemaster Coordinators, Financial Analysts, Compliance Personnel, and Other Interested Personnel