Clinical Documentation

Feeling the Burn: Confessions of a Formerly Burned Out Coder

By Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Ten strategies for avoiding burnout are provided by the author. On any given day, if you walked into my home office, you might think you were in a spa. The walls are painted a soothing aqua color (at least, I think it’s soothing),…

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In Outpatient CDI, Timing is Everything

Article by Susan Richards Morgan, CCS, CPHQ, CPC, CDEO, CRC, CPMA, CEMC, CPC-I. This article was originally published on the A Journal of AHIMA Blog on April 25, 2018 and is republished here with permission. Currently, most clinical documentation improvement (CDI) programs have been developed inside hospitals with an inpatient focus. Medicare generally expects an inpatient admission to need two…

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Auditing Issues Uncovered in Physician Documentation: Part I

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. EDITOR’S NOTE: This is the first in a four-part series that examines physician documentation issues as seen by an auditor. One of the services I offer, aside from coding…

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6 things keeping CIOs up at night

By Beth Jones Sanborn for Healthcare IT News Last month, LexisNexis brought together 30 high-level executives, most of whom were CIOs from hospitals, nursing homes and health plans of all sizes from across the county to find out what data-related issues are weighing on them most as we get further into 2018. Ed Domansky, LexisNexis…

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Proper Documentation is Critical to Our Modern Healthcare System

Article by Allen Frady, RN, BSN, CCS, CCDS, CRC. This article was originally published on the Journal of AHIMA on March 29, 2018 and is republished here with permission. Is documentation improvement and proper use of ICD-10-CM critical to the nation’s healthcare debate? I say definitively yes, in every way. The bulk of the information coming from…

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EHR usability issues may contribute to patient harm, JAMA study shows

By Jeff Lagasse for Healthcare Finance  The usability of electronic health records may be associated with some safety events in which patients were possibly harmed, according to a new study published in the Journal of the American Medical Association. And while the authors did not make any specific financial revelations, clinical quality has increasingly been tied…

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Can Texting Get a Healthcare Provider in Trouble?

Article by Ron Hedges. This article was originally published on the Journal of AHIMA  on March 27, 2018 and is republished here with permission. Can texting get a healthcare provider in trouble? The answer to that question, like many other legal ones, is “it depends.” A recent decision, Latner v. Mt. Sinai Health System, Inc., No. 17-99-cv (2d Cir.…

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