Documentation of Care and Prospective Payment

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Abstract
Hospitals are now being reimbursed by Diagnosis Related Group (DRG) for Medicare patients. The Johns Hopkins Hospital has worked successfully under this system for the past 5 years, with cost increases being maintained well below the national average. Allowable revenue varies considerably by diagnosis depending on such factors as secondary diagnoses, procedure, and patient age. Failure to document accurately may result in substantial loss of hospital income. More worrisome is the use of data by outside agencies to evaluate quality of care. Recent reports of mortality rates for surgery in Maryland hospitals and of permanent pacemaker use are illustrative. Conclusions were inaccurate because of inadequate documentation of diagnoses and procedures by physicians and inaccurate coding by quality assurance coordinators. Surgeons need to be aware that in the prospective payment era, accurate and complete documentation is essential and that their data are likely to be used for purposes other than monitoring fiscal performance.