Maximize the integrity of your medical record to reduce risks and improve patient care. Clinical documentation improvement (CDI) is a process that continually seeks to answer, “How best can we maximize the integrity of the medical record?” Although the goal of CDI is always the same — to provide a complete and accurate picture of ...
In Coding
Jun 20th, 2019
Social determinants of health (SDOH) will play a key role in quality reporting in the coming years. But until just recently physicians did not know the importance of capturing this data in their documentation, and vital diagnosis codes were not being reported. The American Medical Association (AMA) has created a free online education module to ...
In CMS
May 10th, 2019
Rules are changed for teaching physicians documenting Evaluation and Management (E/M) codes being reported to Medicare July 29, 2019. These changes are part of the Center for Medicare & Medicaid Services’ (CMS) revamp of E/M payments. This will affect medical coders and billers, especially those working in clinical documentation improvement. Changes Part of E/M Revamp ...
Clean out old patient health data so only their current and relevant health factors remain. A problem list should be a database of a patient’s diagnoses. The list should be a way to track and share patient information across specialties and places of service. Unfortunately, problem lists have become repositories for current and inactive concerns. ...
In Billing
Mar 26th, 2019
Medical coders who code pass-through drugs or home health have 21 new HCPCS Level II codes to use, effective April 1, 2019. The new codes include drugs for migraines, to initiate blood-clotting in patients on certain coagulants, chronic and hairy cell leukemia, and folic acid for chemotherapy patients. The home health codes help facilitate the ...