The clock is ticking on 2021. Yes, we know that it’s not 2020 yet. But a year from now, the way you code evaluation and management (E/M) office visits is going to change completely. For starters, you will be selecting visit levels based only on time or medical decision making (MDM). There’s a lot to ...
When clinical documentation gets overrun with auto-populated data, it’s time to redirect technology to better serve our patients. Medical providers will no longer be required to document the history/medical interview during outpatient/office services in health records starting Jan. 1, 2021, per the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This new policy is supported ...
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 ...