Clinical Documentation

CMS Eases Meaningful Use Requirements in Proposed Rule

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on July 12, 2016 and is republished here with permission. A new proposed rule would reduce the Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” EHR Incentive Program reporting period for clinicians, hospitals, and critical access hospitals. The new reporting period would…

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4 Stolen Health Databases Reportedly for Sale on Dark Web

Hacker Takes Credit for Theft of Data on Nearly 10 Million Patients By Marianne Kolbasuk McGee for Data Breach Today A hacker is reportedly selling on the dark web copies of databases stolen from three unidentified U.S. healthcare organizations and one unnamed health insurer containing data on nearly 10 million individuals for prices ranging from…

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CDI is Expanding as Need for Quality Documentation Grows

Article by Tammy Combs. This article was originally published on the Journal of AHIMA website on June 23, 2016 and is republished here with permission. Clinical documentation improvement (CDI) programs are quickly emerging in various areas of the healthcare arena. We now see these programs specializing both prior to and beyond the acute hospital admission. Just as…

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Unfinished Business

By Susan Chapman for For The Record Findings from The Joint Commission show many surveyed hospitals house incomplete medical records. When so many aspects of health care revolve around quality documentation, it would be good to know that providers are accomplished medical record custodians. Depending on your perspective, the news on that front isn’t half…

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DEA Wants Inside Your Medical Records to Fight the War on Drugs

By Christopher Moraff for The Daily Beast The feds are fighting to look at millions of private files without a warrant, including those of two transgender men who are taking testosterone. Marlon Jones was arrested for taking legal painkillers, prescribed to him by a doctor, after a double knee replacement. Jones, an assistant fire chief of Utah’s…

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Analyzing Eight Months of ICD-10

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on June, 2016 and is republished here with permission. Teachers know there are two kinds of students. Student A studies and does their assigned reading throughout the whole semester, earning extra credit where they can. When the final exam rolls up, they’re…

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DEVELOPING: CMS Releases 2017 ICD-10-PCS Codes

By Laurie M. Johnson, MS, RHIA, CPC-H, FAHIMA for ICD10 monitor The Centers for Medicare and Medicaid Services (CMS) released the 2017 ICD-10-PCS codes as well as other supporting documentation on Thursday. Before you get excited, the 2017 ICD-10-CM codes have not been released yet. The additional supporting documentation includes the 2017 ICD-10-PCS Official Coding and Reporting…

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Grappling With the End of Physician ICD-10 Coding Grace Period

Article by Mary Butler. This article was originally published on the Journal of AHIMA website on May 19, 2016 and is republished here with permission. October 1, 2016, will mark the end of a one-year “grace period” that allowed unspecified ICD-10-CM codes on certain physician Medicare claims. The grace period was a joint initiative between the Centers…

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Highmark to Pay More for Better Diagnostic Documentation

By Joseph Goedert for Health Data Management Highmark Inc., a Blues plan serving Pennsylvania, Delaware and West Virginia, is giving physicians a financial incentive to increase documentation of diagnostic codes in the electronic health record of patients insured under Medicare Advantage or health insurance exchange programs. Too often, physicians enter a core diagnosis following a…

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