In CMS
Aug 8th, 2018
During a July 18, 2018 CMS Twitter™ podcast, CMS National Coordinator for Health Information Technology, Donald Rucker, M.D. defended the new CMS 2019 proposal to make documentation of the History optional for health records. He was asked, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible ...
In Billing
Apr 5th, 2018
A representative from the Hospital and Ambulatory Policy Group at the Centers for Medicare & Medicaid Services (CMS) held a listening session regarding proposed updates to the documentation guidelines for evaluation and management (E/M) services on March 21st. The listening session was to get feedback from stakeholders on policy proposals for upcoming notice and comment ...
Mar 30th, 2017
Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I have to ask ...
What is the primary driver of an E/M level? Find out what lands the knockout punch. By Brian Meredith, CPC Per the CPT® codebook, medical decision-making (MDM) “refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by” three criteria categories. MDM can be quantified according to this criteria, and ...
Two Medicare cases illustrate the importance of NCDs and LCDs. Proving medical necessity is really no secret at all: Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) dictate which diagnosis codes must be documented by clinicians to support the medical necessity of most services or supplies they provide to patients. Coders who are ...