Clinical Documentation

How to code for lung injuries associated with vaping

From the AAP Division of Health Care Finance New guidance on coding for health care encounters related to e-cigarette, or vaping, product use associated lung injury (EVALI) has been released by the Centers for Disease Control and Prevention’s National Center for Health Statistics. The guidance details the use of International Classification of Diseases, Tenth Revision,…

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4 reasons for medical coders to query a provider about documentation

By Kelly Gooch for Becker’s Hospital Review With documentation queries to providers, it is important for coding professionals, clinical documentation improvement professionals and other healthcare professionals to know the most appropriate times to query, according to a post on the American Association of Professional Coders website. The post — written by Vicky Schack, compliance program…

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Preparing Noncoders for New 2020 Codes

By Maureen Kelly and Fred Wulf for For the Record In August, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule for fiscal year 2020’s inpatient prospective payment system (IPPS) and outpatient prospective payment system (OPPS) code set changes. IPPS updates take effect for discharges occurring from October 1, 2019, through September…

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The Qualification Question

By Selena Chavis for For the Record On what side of the clinical validation argument do HIM professionals fall? Are seasoned coding professionals competent or trained well enough to interpret clinical terms and concepts from the medical record? This question was posed on a Talk Ten Tuesdays podcast last year, and the robust response received…

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Inaccuracies found in physician residents’ EHR documentation

By Jeff Lagasse for Healthcare Finance Emergency department residents do what all physicians do: They document patient encounters into an electronic health record. But the information they’re entering may not be all that accurate. A study published in JAMA Network Open tasked 12 observers with following nine physician residents as they documented patient encounters into…

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Clinician burnout: Physicians name the technologies they think could best solve it

By Mike Miliard for Healthcare IT News SANTA CLARA – At Health 2.0 on Monday, National Coordinator for Health IT Dr. Don Rucker listed a litany of challenges faced daily by physicians and nurses, and contributing to the ongoing scourge of clinician burnout: onerous documentation requirements, boilerplate electronic health records and the “monster burdens” of…

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Denial Reasons You Never Saw Coming

By Jacqueline Thelian, CPC, CPC-I, CHCA, CPMA for For the Record Many health care organizations can relate to the following scenario: An insurance carrier, Medicare, or a Medicaid HMO requests medical records for the purpose of an audit. The provider believes it has forwarded all the necessary supporting documentation, but the results indicate a 90%…

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How Will FY2020 IPPS Proposed Rule Affect Hospital CDI Programs?

By Shannon Wiggins for HIT Consultant In April, Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2020 inpatient prospective payment systems (IPPS) proposed rule. The proposed rule notably includes approximately 1,500 complications or comorbidities (CC)/major complications or comorbidities (MCC) designation changes and 324 changes to International Classification of Diseases (ICD)-10-CM codes, along…

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