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By Linda Jones, Speech Recognition Analyst at Dolbey When a facility is looking for speech recognition technology, it must ensure it chooses a highly accurate and reliable application. While this can be a daunting task, an even bigger challenge is selecting a solution that can obtain widespread adoption throughout the facility. When researching and comparing speech…
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 Sara Reader, MD, MPH for KevinMD.com The recent suicides of an NYU resident and a medical student highlight the growing mental health problem among physicians and physicians-in-training in this country. This crisis is certainly not exclusive to physicians, as evidenced by the suicides of designer Kate Spade and television personality Anthony Bourdain. However, suicide…
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…