Clinical Documentation

Certain ICD-10 Codes Often Precede Multiple Sclerosis Diagnosis

For Health Day FRIDAY, June 25, 2021 (HealthDay News) — Certain International Classification of Diseases (ICD), Tenth Revision (ICD-10) codes are recorded more frequently before the initial diagnosis in patients with multiple sclerosis (MS) compared with patients with other autoimmune diseases or individuals without these diseases, according to a study published in the June 15…

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ACDIS tip: Pneumonia documentation

By Kathryn Fallah from ACDIS CDI Blog According to the World Health Organization , pneumonia is a form of an acute respiratory infection that inflames the lungs. When CDI professionals review the record and ensure that the documentation of pneumonia is accurate and complete, they can impact reimbursement, risk of mortality scores, and risk adjustment. There are…

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Nursing leaders share strategies for reducing documentation burden

By Kat Jercich for Healthcare IT News The root causes of nursing burnout are varied – as are potential solutions for it. However, given that nurses are frequently responsible for clinical documentation, it’s perhaps not surprising that reducing documentation burden is frequently cited as a key strategy for fighting burnout. Whether it’s through more in-depth electronic health record…

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Chart Conundrums: Queries: Moving Beyond Business as Usual to Identify Learning Opportunities

By Clarissa Barnes, MD for For The Record While often said in jest, my dislike of getting queries delivered to my inbox is (at least indirectly) 100% responsible for my work as a physician advisor. Queries were an intrusion in my otherwise organized workflow. It seemed like my only option was to keep answering them…

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The best way for hospitals to avoid revenue loss: 2 execs weigh in

By Katie Adams from Becker’s Hospital Review U.S. hospital margins are remaining narrow, prompting healthcare revenue cycle leaders to examine their processes and make sure no money is falling through the cracks. Donna Ellenburg, revenue cycle director at Birmingham, Ala.-based Grandview Medical Center, said hospitals can avoid losing revenue by adhering to the following process: verifying…

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How CMS final rule will impact E/M coding and documentation requirements

By Ben Howard for Med City News This year ushered in many changes affecting reimbursement for healthcare providers, but few are as important as the new Physician Fee Schedule from the Centers for Medicare & Medicaid Services (CMS) and the updated coding guidelines for Evaluation and Management (E/M) services from the American Medical Association. For…

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Busy ED Environment Breeds Documentation Lapses

By Elizabeth S. Goar for Becker’s Hospital Review When it comes to emergency department activities, documentation doesn’t jump immediately to mind. Far from it, in fact, but that doesn’t mean it’s not vital to an organization’s financial well-being. With emergency department (ED) visits climbing steadily, along with case acuity and complexity, it’s a service line…

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Molding Tomorrow’s HIT Professionals

By Susan Chapman, MA, MFA, PGYT for For the Record As the health care industry continues to evolve, an important question has come to the forefront: How is higher education addressing the demands and changes while also producing prospective employees who will become reliable contributors upon graduation? Addressing Industry Demands Peter Winkelstein, MD, Kaleida Health’s…

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