Clinical Documentation

The Qualification Question

By Selena Chavis for For the Record On what side of the clinical validation argument do HIM professionals fall? Are seasoned coding professionals competent or trained well enough to interpret clinical terms and concepts from the medical record? This question was posed on a Talk Ten Tuesdays podcast last year, and the robust response received…

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Inaccuracies found in physician residents’ EHR documentation

By Jeff Lagasse for Healthcare Finance Emergency department residents do what all physicians do: They document patient encounters into an electronic health record. But the information they’re entering may not be all that accurate. A study published in JAMA Network Open tasked 12 observers with following nine physician residents as they documented patient encounters into…

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Clinician burnout: Physicians name the technologies they think could best solve it

By Mike Miliard for Healthcare IT News SANTA CLARA – At Health 2.0 on Monday, National Coordinator for Health IT Dr. Don Rucker listed a litany of challenges faced daily by physicians and nurses, and contributing to the ongoing scourge of clinician burnout: onerous documentation requirements, boilerplate electronic health records and the “monster burdens” of…

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Denial Reasons You Never Saw Coming

By Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA for For the Record Many health care organizations can relate to the following scenario: An insurance carrier, Medicare, or a Medicaid HMO requests medical records for the purpose of an audit. The provider believes it has forwarded all the necessary supporting documentation, but the results indicate a 90%…

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How Will FY2020 IPPS Proposed Rule Affect Hospital CDI Programs?

By Shannon Wiggins for HIT Consultant In April, Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2020 inpatient prospective payment systems (IPPS) proposed rule. The proposed rule notably includes approximately 1,500 complications or comorbidities (CC)/major complications or comorbidities (MCC) designation changes and 324 changes to International Classification of Diseases (ICD)-10-CM codes, along…

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How AI can transform hospital revenue cycle management — 5 thoughts

Scott Becker and Ayla Ellison for Becker’s Hospital Review Artificial intelligence is making big waves across many industries, and healthcare organizations are exploring ways to harness AI’s transformative power. Many hospitals and health systems are already leveraging AI to improve care, support clinical decisions and boost clinician satisfaction. However, the role of AI in healthcare…

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ICD-10-PCS changes: 20 codes added for FY 2020

By Kelly Gooch for Becker’s Hospital Review CMS has provided ICD-10 Procedure Coding System updates for fiscal year 2020 that include 734 additions. Here are 20 of the added codes: 3E0M30Y Introduction of hyperthermic antineoplastic into peritoneal cavity, percutaneous approach 3E1U48X Irrigation of joints using irrigating substance, percutaneous endoscopic approach, diagnostic 3E1U48Z Irrigation of joints using irrigating…

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Poor documentation training cited as one reason for possible hospital closure

Published July 2019 from CDI Strategies on acdis.org   Citing severe financial difficulties, Hahnemann University Hospital in Philadelphia will close its doors in early September of this year with inpatient admissions ceasing in July, according to a FAQ on the hospital’s website. Since its purchase by the California-based American Academic Health System in January 2018,…

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Primary care, younger docs more likely to report burnout

By Shannon Muchmore for Healthcare Dive Dive Brief: Nearly 80% of primary care physicians and 57% of specialists reported some level of burnout in a recent online survey of more than 600 physicians conducted by InCrowd, a vendor of market research for life sciences companies. Burnout rates were highest among younger physicians — 70% for…

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