Clinical Documentation

CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…

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Ransomware Cyber Attacks: How to Prepare & Respond

By Christine Bucci for BRITTON GALLAGHER Hackers are wielding their power across Europe by unleashing a rash of ransomware cyber attacks on companies, with the most severe hitting the Ukraine. Ransomware is a type of malware that holds your computer and data files hostage until the ransom pays the demanded amount. In the most recent European…

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Survey: Hospital, Office Physicians Say EHRs Hinder Patient Interaction, in Different Ways

By Heather Landi for Healthcare Informatics While it’s no secret that physicians have complaints about electronic health records (EHRs) and the impact on patient interactions, one survey has found that hospital-based physicians and office-based physicians have slightly different concerns about how maintaining electronic records impacts clinical encounters. An analysis by researchers at Brown University and…

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Has CAC Lived Up to Its Promise? Providers, Vendors Weigh In

Article by Lisa A. Eramo, MA. This article was originally published on the Journal of AHIMA website on June 1, 2017 and is republished here with permission. In the months leading up to the ICD-10 go-live, many hospitals implemented computer-assisted coding (CAC) in the hopes that it would offset anticipated productivity losses and boost coding accuracy. Now…

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Christie: Opioid Commission May Propose Changing HIPAA Rules

By Katherine Landergan for POLITICO MORRISTOWN — The presidential opioid commission may propose changing patient privacy regulations so there are clear exemptions for overdose cases, Gov. Chris Christie, the commission chairman, said Monday. Christie said the commission could recommend a retooling of the Health Insurance Portability and Accountability Act of 1996, or HIPAA, so physicians…

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OIG Estimates $729.4M in Erroneous EHR Incentive Payments

By Kate Monica for EHR Intelligence OIG estimates 12 percent of the total Medicare EHR incentive payments issued to EPs between 2011 and 2014 were made incorrectly. CMS overpaid an estimated $729.4 million in Medicare EHR incentive payments to eligible professionals (EPs) who failed to meet meaningful use requirements, the Office of Inspector General (OIG)…

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Dolbey to Offer Physician Query Mobile App for CAC and CDI with Artifact Health

Dolbey’s award winning Computer-Assisted Coding application and new Clinical Documentation Improvement offering will now include the power and convenience of mobile physician queries and enhanced query management and reporting through Artifact Health. Dolbey’s Fusion CAC™ is deployed in the medical coding process.  Fusion CAC evaluates the patient chart documentation to suggest diagnostic and procedure codes…

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To Query or Not to Query? That Is the Question

Article byHarvey Bair, RN, PhD, CCDS, CRC. This article was originally published on the Journal of AHIMA website on April 28, 2017 and is republished here with permission. Do you find yourself wondering what to focus on when querying for ICD-10 specificity? Are you concerned that your organization’s query process may overwhelm providers? You are not alone; the…

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Leapfrog Group Releases 2017 Hospital Grades

By Staff for HealthLeaders Media The five states with the highest percentage of “A” hospitals this spring are Maine, Hawaii, Oregon, Wisconsin, and Idaho. The Leapfrog Group  released its latest “safety grades” Wednesday for the 2,639 hospitals participating in the group’s annual survey. Of that group, 31% (823) earned an “A” and 27% (706) earned a…

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Ransomware and Hacking Attempts against Healthcare Expected to Increase in Severity, Scope

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on November 21, 2016 and is republished here with permission. If it seems like news reports about hacking and ransomware attacks against healthcare organizations are on an uptick. The infamous Department of Health and Human Service’s “wall of shame” confirms this trend.…

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