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By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner for ICD10 Monitor Questions abound when reporting critical care services. Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care. Many questions come up when reporting…
By John Lauerman and Jeran Wittenstein, with assistance by Joshua Fineman and Saritha Rai for Bloomberg Technology Many doctors still can’t use a transcription service made by Nuance Communications Inc. three weeks after the company was hit by a powerful, debilitating computer attack. Hospital systems including Beth Israel Deaconess in Boston and the University of Pittsburgh Medical Center…
By Lee DeOrio for For The Record In the face of a crisis, it’s often a good idea to take a step back and learn from the moment. Perhaps that’s not feasible until after the fact—it certainly isn’t in this case—but to place odds on it never happening again is foolish. On June 27, Nuance…
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…
By Susan Chapman for For The Record Findings from The Joint Commission show many surveyed hospitals house incomplete medical records. When so many aspects of health care revolve around quality documentation, it would be good to know that providers are accomplished medical record custodians. Depending on your perspective, the news on that front isn’t half…
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…
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…
By Max Green for Becker’s Health IT & CIO Review More than half of the physicians who bill Medicare in the U.S. are currently being penalized 1 percent of their 2015 payments as a result of the meaningful use program, according to Steven J. Stack, MD, president of the American Medical Association. “Imagine, in a world…
By Akanksha Jayanthi and Max Green for Becker’s Health IT & CIO Review January 15, 2016 While CMS Acting Administrator Andy Slavitt’s announcement of the end of meaningful use was met with a collective sigh of relief from the healthcare industry, questions, concerns and expectations regarding the future remain. Though frustrating, many IT leaders do…
Sharing documentation best practices is a win-win for healthcare stakeholders. By Bonnie Bakal for Advanced Healthcare for Health Information Professionals One of my all-time favorite song lyrics is from Josh Groban’s You Raise Me Up and goes: “I am strong when I am on your shoulders, You raise me up to more than I can…