Risks Associated with Critical Care Coding

By Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner for ICD10 Monitor Questions abound when reporting critical care services. Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that go along with critical care.  Many questions come up when reporting…

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Cyberattack on Medical Software Shows Industry Vulnerability

By John Lauerman and Jeran Wittenstein, with assistance by Joshua Fineman and Saritha Rai for Bloomberg Technology Many doctors still can’t use a transcription service made by Nuance Communications Inc. three weeks after the company was hit by a powerful, debilitating computer attack. Hospital systems including Beth Israel Deaconess in Boston and the University of Pittsburgh Medical Center…

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CDI in the Outpatient Setting: Finding the ‘Hidden Gems’ of Opportunity for Improvement

By Kay Merriweather, RHIA, CCS, CCS-P, COC, CHDA, CDIP; Leslie Slater, RHIA, CCDS, CIC, CRC; and Michele Bohley, RHIA, CCS for AHIMA “If it’s not documented, it wasn’t done.” This is one of the first axioms health information management (HIM) professionals learn. HIM professionals have witnessed the evolution of quality documentation, with patient education becoming…

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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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