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By Howard Rodenberg, MD, MPH, CCDS for ACDIS CDI Blog I think we’re all familiar with the Law of Unintended Consequences. That’s the concept that something begun with the best of intentions can wind up going horribly awry. Examples include “New Coke” and anything ending in the word “Kardashian.” (Although I’m not sure anything the…
By Jasmine Morgan for Technology Networks Medical records are some of the richest and most under-utilized data sources. Imagine if you could search medical records in the same way you search Google. This would require that all the information was properly categorized and tagged. Such a tool would offer all members of the medical staff…
By Morgan Haefner for Becker’s Hospital Review In June, federal officials charged 601 defendants in alleged schemes involving about $2 billion in costs to Medicare and Medicaid, the biggest healthcare fraud enforcement action in U.S. Justice Department history. Government and private health insurer audits have recently revealed several fraudulent or abusive medical billing practices, Kevin B. O’Reilly, editor…
By Cindy Parman, CPC, CPC-H, RCC for For the Record A current urban myth opines that it’s not necessary for physician practices to employ coders because software can capture charges when the work has been completed. Or, since the physician performed the work, it’s easier for him or her to assign the codes. In an…
By Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Clinical documentation will need to reflect these situations in order to be accurately coded. When beginning research for this article, I opened my 2018 ICD-10-CM book to the External Cause Index section, specifically for the word “harassment,” but it was missing. The…
By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor. Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I Click here to read…
By Marisa MacClary for For the Record The only way hospital clinical documentation improvement (CDI) and coding staff may compliantly clarify physician documentation for the purpose of accurate coding is to query the physician. The physician query process is essential to ensure accurate quality scores and proper reimbursement. However, most CDI specialists, coders, and physicians…
By Erica E. Remer, MD, FACEP, CCDS for ICD10 Monitor Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT). Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse,…
By Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer for ICD10 Monitor Strive to achieve coding compliance that really works. I’m often asked about how one would or should strive for coding compliance and make it happen. The first thing I do is to identify and acknowledge the risks or potential risks that occur.…
By Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM for ICD10 Monitor CDI, when properly performed, supports the ancient physician oath, “First, do no harm.” Clinical Documentation Improvement Specialists(CDISs) play a vital role in the overall scheme of healthcare delivery through affecting measurable meaningful improvement in the quality, completeness, and accuracy…