medical coding

CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

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…

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Has CAC Lived Up to Its Promise? Providers, Vendors Weigh In

Article by Lisa A. Eramo, MA. This article was originally published on the Journal of AHIMA website on June 1, 2017 and is republished here with permission. In the months leading up to the ICD-10 go-live, many hospitals implemented computer-assisted coding (CAC) in the hopes that it would offset anticipated productivity losses and boost coding accuracy. Now…

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Dolbey to Offer Physician Query Mobile App for CAC and CDI with Artifact Health

Dolbey’s award winning Computer-Assisted Coding application and new Clinical Documentation Improvement offering will now include the power and convenience of mobile physician queries and enhanced query management and reporting through Artifact Health. Dolbey’s Fusion CAC™ is deployed in the medical coding process.  Fusion CAC evaluates the patient chart documentation to suggest diagnostic and procedure codes…

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Dolbey, Maxim Partner to Offer RCM Services: 3 Things to Know

By Kelly Gooch for Becker’s Hospital CFO Computer software company Dolbey partnered with health information management and revenue cycle management services provider Maxim Healthcare Services. Here are three things to know about the partnership. 1. Through the partnership, Dolbey customers will be able to access Maxim’s staff for auditing, clinical documentation improvement, coding and other…

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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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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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12 Days of Christmas

In the true spirit of the holidays, I am sharing an ICD-10 coding gift that was given to me in hopes that you will enjoy it as much as I did. Thank you, Annie Boynton, BS, CPC, COC (formerly CPC-H), CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT. Your clever mind, generosity, and humility have no limits.…

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The Essentials of Medical Necessity

By Laurie Desjardins, CPC-I for For The Record Vol. 27 No. 11 P. 6 The Social Security Act defines medical necessity as follows: “Notwithstanding any other provisions of this title, no payment may be made under Part A or Part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis…

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