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By Cindy Parman, CPC, CPC-H, RCC for For the Record A current urban myth opines that it’s not necessary for physician practices to employ coders because software can capture charges when the work has been completed. Or, since the physician performed the work, it’s easier for him or her to assign the codes. In an…
By Megan Knowles for Becker’s Hospital Review Although hospitals may aim to control how providers visually present themselves to patients, whether a physician has visible tattoos or piercings did not affect patient satisfaction levels, a study published in Emergency Medicine Journal found. “We were inspired to conduct this study because hospitals have many rules around…
By Laura Baukol for nVoq Mirroring national trends, the Stanford doctors who responded to both the 2013 and 2016 surveys expressed increased burnout and decreased professional fulfillment. In fact, there was a 13 percent increase between 2013 and 2016 for those who self-reported burnout. In addition, the survey found those who indicated that they held a…
By Linda Jones, Speech Recognition Analyst at Dolbey When a facility is looking for speech recognition technology, it must ensure it chooses a highly accurate and reliable application. While this can be a daunting task, an even bigger challenge is selecting a solution that can obtain widespread adoption throughout the facility. When researching and comparing speech…
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Clinical documentation will need to reflect these situations in order to be accurately coded. When beginning research for this article, I opened my 2018 ICD-10-CM book to the External Cause Index section, specifically for the word “harassment,” but it was missing. The…
By Sara Reader, MD, MPH for KevinMD.com The recent suicides of an NYU resident and a medical student highlight the growing mental health problem among physicians and physicians-in-training in this country. This crisis is certainly not exclusive to physicians, as evidenced by the suicides of designer Kate Spade and television personality Anthony Bourdain. However, suicide…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor. Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I Click here to read…
By Marisa MacClary for For the Record The only way hospital clinical documentation improvement (CDI) and coding staff may compliantly clarify physician documentation for the purpose of accurate coding is to query the physician. The physician query process is essential to ensure accurate quality scores and proper reimbursement. However, most CDI specialists, coders, and physicians…
By Alia Paavola for Becker’s Hospital Review Police are investigating Zuckerberg San Francisco General Hospital after a second woman was found dead in a hallway June 4, according to an NBC Bay Area report. The death comes one week after 75-year-old Ruby Anderson was found dead in the stairwell of a locked power plant building…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT). Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse,…