Clinical Documentation

The ICD-11 Clock Is Ticking

By Selena Chavis for For the Record Is it time for health care organizations to start thinking about it? On the ICD-11 front, two significant milestones occurred last year: The World Health Organization (WHO) officially released the 11th edition of the International Classification of Diseases (ICD-11) and the World Health Assembly formally adopted ICD-11. Now…

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AMA Announces New CPT Codes as COVID-19 Advancements Expand

From For the Record The American Medical Association (AMA) recently published an update to the CPT code set that includes two code additions for reporting medical services sparked by the public health response to the COVID-19 pandemic. The update to the CPT code set was approved by the CPT Editorial Panel, the independent body convened…

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AMA releases 329 CPT code changes for 2021: 6 things to know

By Alia Paavola for Becker’s Hospital Review The American Medical Association released updates Sept. 1 to its Current Procedural Terminology code set for 2021. Six things to know about the changes: The AMA has made 329 changes to the 2021 CPT code set, including 206 new codes, 54 deletions and 69 revisions. The changes will take effect…

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AI-assisted EHR documentation will need human help

By Kat Jercich for Healthcare IT News Artificial intelligence technologies are being increasingly relied upon in the healthcare domain, particularly when it comes to decision support, precision medicine, and the improvement of the quality of care. Regarding primary care specifically, AI also represents an opportunity to assist with electronic health record documentation. A new study…

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ICD-10 codes don’t accurately capture COVID-19 symptoms, study shows

Kat Jercich for Healthcare IT News A study published this past week in JAMA Network Open suggests symptom-specific ICD-10 codes don’t always capture COVID-19-related symptoms. An electronic health record review of 2,201 patients who had been tested for COVID-19 found that ICD-10 codes had low sensitivity and negative predictive value for capturing cough, fever and…

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Contributor: Agility Required to Keep Pace With Code Changes During Pandemic

By Andria Jacobs, RN, MS, CEN, CPHQ for AJMC Andria Jacobs, RN, MS, CEN, CPHQ, chief operating officer for PCG Software, discusses 3 billing and claims issues facing the health care industry in the wake of the COVID-19 pandemic. Rightfully so, the coronavirus pandemic has shone the spotlight on front-line medical professionals who continue to…

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Code changes coming for evaluation and management visits: 4 things to know

Morgan Haefner for Becker’s Hospital Review In its proposed Physician Fee Schedule for 2021, CMS outlined changes to how office and outpatient evaluation and management visits will be coded. Four things to know: 1. CMS proposed a refinement to clarify the times when prolonged office and outpatient E/M visits can be reported. The department proposed revaluing…

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11 CPT codes take effect for ASCs

By Angie Stewart for Becker’s Hospital Review CMS published 11 Current Procedural Terminology Category III codes that took effect July 1 in the ASC payment system. The agency also made updated payment rates available for download. The new codes: 0594T. Humerus osteotomy with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments,…

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Guest post: Most common COVID-19 respiratory manifestations

By Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC for ACDIS CDI Blog In their review of the medical record, CDI professionals aim to reconstruct the patient story from admission to discharge by examining, understanding, and synthesizing many puzzle pieces from disparate systems and people. Many patients coming in with COVID-19 related pneumonia are demonstrating…

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