Why does documentation matter?

We know that payers will be looking at the data that they will receive to measure safety, quality and establish "profiles" for providers and hospitals. 

Quality is measured from codes! 
Ex: If a patient dies from septic shock but the discharge summary reports "fever", it looks as if a healthy person (with fever) died!

The following is from CMS website:  ICD-10 codes enable the capture of more accurate data, which enables fair and equitable reimbursement policies for new technologies and more accurate payments/reimbursement rates for new procedures. ICD-10 codes provide richer data from the claims process that could inform changes and improvements to payment policy and allow for the design of better health care delivery systems. 

So providers have every incentive to pay attention to everything they place on the chart. remember this:

"Describe on paper (or electronically) how the patient looks in the bed."

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