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By Angie Comfort, RHIA, CDIP, CCS, CCS-P for For the Record In October 2017, the Department of Health and Human Services (HHS) declared a public health emergency to focus on the opioid crisis. Analyzing data from 2000 to 2015, HHS estimated that 91 Americans had died of opioid overdoses each day, and the numbers have…
By Steve Kraus for CNBC Apple made a big splash in health care circles this past week when it announced that the company is entering the personal health record space with Apple Health, a new feature that will interface with electronic health records at a dozen hospitals. For the past two years, Apple has been…
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…
Three questions to consider when evaluating a clinical documentation improvement program. By Lisa A. Eramo, MA for For the Record Review the record. Query the physician. Obtain the diagnosis. Repeat. Does this clinical documentation improvement (CDI) workflow sound familiar? Productivity is the hallmark of a good program. Or is it? On the surface, CDI specialists…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Dieticians’ findings must find their way into the medical record to achieve proper care and coding. Diagnosing malnutrition is not diving for dollars. Malnutrition – and I am specifically talking about undernutrition today – is a common but frequently unrecognized problem that leads to difficulty…
By Angie Dibble, RHIT for For the Record Remember when we thought of medical charts as inanimate objects, safely tucked away on a dusty shelf in a paper mill known as “Medical Records”? In my prior life, the one I innocently enjoyed before working in health information, I believed all medical charts were somehow pure…
By Naseem S. Miller for Orlando Sentinel The number of babies who were exposed to opioids in the womb jumped by 200 percent in Florida between 2015 and 2016 — to more than 2,500 cases — the biggest spike in the past decade, according to state data. But the number of newborns statewide who were…
By Angie Dibble, RHIT for For The Record Sepsis, encephalopathy, malnutrition, and acute renal failure are examples of diagnoses that often prove vexing for coders and clinical documentation improvement (CDI) specialists. What if the sepsis diagnosis is based on “technically meets sepsis criteria” because a patient with a urinary tract infection has an elevated white blood…
As health systems work to get the most from their physicians’ EHR charting, experts say it’s important to focus on the right metrics while working toward greater buy-in from doctors. By Mike Miliard for Healthcare IT News Hospitals and health systems trying to survive and thrive under value-based reimbursement realize that optimal clinical documentation is…
By Robert Pearl, M.D. for Forbes Over the past seven seasons, Game of Thrones fans have demonstrated the ability to spot an emerging threat early on – a quality more leaders in healthcare need to possess. If you’ve tuned into the popular HBO series from the beginning, you likely recall Ned Stark (Lord of Winterfell)…