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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 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 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 The Medical Futurist Team for The Medical Futurist The medical community should not fall for the fearmongering around A.I. At the dawn of the Fourth Industrial Revolution, automation and digitization are turning the job market upside down. Many fear that robots, A.I., and automation, in general, will take their jobs without alternatives. The same…
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor CDI, when properly performed, supports the ancient physician oath, “First, do no harm.” Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy…
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 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…