Both hospitals and individual physicians are under increasing scrutiny to comply with documentation requirements as outlined by the Centers for Medicare and Medicaid Services (CMS). In October 2007, CMS implemented a complete reformulation of documentation requirements for hospitalized patients resulting in the creation of the MS-DRG. MS-DRG’s:  

• Are the basis for reimbursement to hospitals

• Serve as a basis for measuring the quality of inpatient care provided by specific hospitals

• Are used to compare the quality of inpatient care provided among similar hospitals

• Will be used, in part, in the near future as a measure of the quality of inpatient care provided by individual physicians.

This web-based curriculum is designed as an interactive tool that will provide clinicians with the background to understand the requirements for CMS-approved documentation in hospitalized patients and how to practically implement these requirements into everyday physician practice.

To begin, view this introductory presentation for an overview of inpatient effective documentation. When done, select a link below to explore and apply effective documentation skills for the respective diagnoses.