Clinical Documentation

Analyzing Eight Months of ICD-10

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on June, 2016 and is republished here with permission. Teachers know there are two kinds of students. Student A studies and does their assigned reading throughout the whole semester, earning extra credit where they can. When the final exam rolls up, they’re…

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DEVELOPING: CMS Releases 2017 ICD-10-PCS Codes

By Laurie M. Johnson, MS, RHIA, CPC-H, FAHIMA for ICD10 monitor The Centers for Medicare and Medicaid Services (CMS) released the 2017 ICD-10-PCS codes as well as other supporting documentation on Thursday. Before you get excited, the 2017 ICD-10-CM codes have not been released yet. The additional supporting documentation includes the 2017 ICD-10-PCS Official Coding and Reporting…

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Grappling With the End of Physician ICD-10 Coding Grace Period

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on May 19, 2016 and is republished here with permission. October 1, 2016, will mark the end of a one-year “grace period” that allowed unspecified ICD-10-CM codes on certain physician Medicare claims. The grace period was a joint initiative between the Centers…

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Highmark to Pay More for Better Diagnostic Documentation

By Joseph Goedert for Health Data Management Highmark Inc., a Blues plan serving Pennsylvania, Delaware and West Virginia, is giving physicians a financial incentive to increase documentation of diagnostic codes in the electronic health record of patients insured under Medicare Advantage or health insurance exchange programs. Too often, physicians enter a core diagnosis following a…

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3rd Biggest Killer in US Is Medical Error – Johns Hopkins Study

By Staff for RT Research has discovered that medical error is the third leading cause of death in the United States. With more than 250,000 deaths of this kind annually, researchers from Johns Hopkins University urge addressing systemic problems with the US system. There have been other estimates, including one by the Centers for Disease Control…

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Physician Advisors

By Dr. Jon Elion for ChartWise Medical Systems, Inc. The Clinical Documentation Specialist (CDS) looked a little tentative stepping up to the microphone to ask her question. I had just finished a talk where I shared stories about Clinical Documentation Improvement (CDI) from the point of view of a practicing physician. As her question unfolded, the…

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Words Matter: Best Practices for Dictating in an EMR Setting

By Selena Chavis for For The Record Vol. 28 No. 4 P. 14 As HIT matures, dictation and transcription models continue to evolve. It’s a situation being closely monitored by health care organizations concerned about the fallout from potential productivity losses and physician outcry over clunky EMR documentation workflows. To combat these fears, many facilities are…

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Time to Capture Data in a Way Not Burdensome to MDs

By Mark Hagland for HCI | Healthcare Informatics Rush University Medical Center CMIO Brian Patty, M.D., shares his perspectives on physician documentation reform As the implementation of electronic health records (EHRs) has moved towards universalization, one of the unfortunate unintended consequences of the rapid shift to electronic form for patient records has been that of…

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ICD-10 to Get 5,500 New Codes, Including Ones for Face, Hand Transplants, CMS Says

By Susan Morse for Healthcare IT News CMS said it plans to add about 1,900 diagnosis codes and 3,651 hospital inpatient procedure codes to the coding system. On Oct. 1, the Centers for Medicare and Medicaid Services will add another 5,500 codes to the ICD-10 diagnostic library, officials announced in a March 9 meeting. The addition will…

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