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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 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,…
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Strive to achieve coding compliance that really works. I’m often asked about how one would or should strive for coding compliance and make it happen. The first thing I do is to identify and acknowledge the risks or potential risks that occur.…
By Jeff Legasse for Healthcare Finance News These days, Americans can manage many facets of their lives through the internet. But a new poll suggests many older adults still aren’t using online systems to communicate with doctors and other healthcare providers, despite the widespread availability of such systems. As patients age and have more complex…
By Leo Vartorella for Becker’s Hospital Review Fortune released its 64th annual list of the 500 most profitable American companies May 21, with 40 healthcare companies making the cut. Companies are ranked in order of their total revenues in the last fiscal year. Only companies incorporated and operating in the U.S. are eligible for inclusion…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you? Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…
By Meg Bryant for Healthcare Dive Brief: Physicians unhappy with an EHR system could pass that sentiment on to their patients — in the form of lower patient satisfaction scores. That’s according to a new study in the Journal of the American Medical Informatics Association. The researchers looked at how the installation of an ambulatory…
By Kelly Gooch for Becker’s Hospital Review Healthcare jobs are expected to grow significantly faster than the rest of the economy over the next decade, according to an analysis of Bureau of Labor Statistics data. For the analysis, researchers with the Center for Health Workforce Studies — a part of the School of Public Health…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. Click here…