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No one relishes a coding query.Mention a query to coding staff and you may get some eye rolls. Coders get anxiety when writing them, leadership wants less of them to keep the discharged not final billed (DNFB) down and revenue flowing, physicians get irritated by receiving them, and the list…
It has been almost a week since I published a rant about my many complaints with regard to ICD-10 or the state of affairs concerning audits and “clinical validation.” In a departure from my usual editorialized op ed, I wanted to shift gears and write about something from a more academic…
While it is now officially calendar year 2017, we are a full quarter into the 2017 federal fiscal year. That said, it is not too late to think about what you as a leader of a clinical documentation improvement (CDI) or coding department can resolve to do to improve your…
Got denials?   This article is about building relationships between hospitals and payers. Hospitals in our country are currently taking one or more of the following three steps in some form, with the goal of reaching agreements with insurance companies and other payers.Step No. 1: Documentation“Code assignment is not based on…
ExtStore.AdvPoll.initResult(); What is your overall ICD-10 coding accuracy? jQuery(document).ready(function() { var $wrapper = jQuery('.advpoll-wrapper-11'); $wrapper.find('.advpoll-answer-graph').each(function() { var $this = jQuery(this); $this.find('.advpoll-answer-line').width(0).animate({ 'width': $this.data('percent') }, 900); $this.find('.advpoll-answer-line-percent').width(0).animate({ 'width': $this.data('percent') }, 900); }); }); 90-100% 41.84% 80-89% 12.24% 70-79% 2.04% 69% or lower 0% We have not done an assessment since the…
The subject of ethics made headline news last week when House Republicans voted in secret to scrap the Office of Congressional Ethics – only to rescind their move to gut the independent body later. Meanwhile, a different move was unfolding recently at the American Health Information Management Association (AHIMA), which…

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Jan. 1 always brings fresh starts, both personal and professional. Many of us focus on how we can make improvements for the new year. Whether it is fitness, motivational, financial, or transformational, they all require the same thing: dedication and consistency. The same holds true in our professional lives, and January…
The Healthcare Cost and Utilization Project (HCUP) released a report in May 2016, National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013, outlining which medical conditions were the most expensive to treat.This report provided statistics by payer as well as overall, and it encompassed 35.6 million inpatient stays…
The American Health Information Management Association (AHIMA) House of Delegates approved the newest version of its Standards of Ethical Coding on Dec. 12, 2016. This document provides a solid foundation of guidance in relation to ethical coding practices and actions. The Standards are a form of guidance that promotes a level…
Well, it has started happening.As I feared, there are coders who want to link any and all hypertensive patients who also happen to have chronic heart failure (CHF) and/or renal failure all together.     “So, what is wrong with that?” You may ask. The problem is that they are doing it even when…
When I first entered the CDI field in 2012, I was taught that the acronym stood for clinical documentation improvement. Several years later, my department at University Hospitals Health System in Cleveland transitioned to calling it clinical documentation integrity, and we got new lab coats! I Googled it to determine when the…
As we know, Hierarchical Condition Categories (HCCs) are used as a reimbursement methodology, quality measurement, and chronic care monitoring tool in Medicare Advantage and Patient Protection and Affordable Care Act (PPACA) health plans, as well as with some Accountable Care Organizations (ACOs) and other value-based, risk-sharing provider groups.But for the…
While I was traveling to the airport last week, our local radio station had an allergist as a guest on their early morning talk show. The allergist was reporting that the holiday season is a very dangerous time for people who have food allergies.For one thing, people are attending parties…
One of the hardest jobs for coders is to translate physician terminology into ICD-10 coding terminology. This has been especially challenging with codes related to mental and behavioral health. In some cases during the year following ICD-10 implementation, there was no way to convert DSM-5 terminology used by psychiatrists and…
There's a national epidemic that is significantly impacting America's hospitals. It is the tyranny of DRG downgrading. No doubt you and your facility are also struggling to comply with professional coding and billing standards while having to address the often arbitrary requirements of third-party vendors. You must adhere to legal…
SPECIAL GUEST James P. Jones, MD Mount Sinai Health System ALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; Holly Louie, RN, CHBME; and Edward Roche, PhD, JD

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EDITOR’S NOTE: James Jones, MD, senior medical director of clinical documentation and quality improvement (CDQI) at Mount Sinai Health System in New York, will conduct a webcast on Thursday, Dec. 15, 2016 during which time he will update attendees on Mount Sinai's battle against diagnosis-related group (DRG) downgrading caused by cyber audits.Examination…
EDITOR’S NOTE: Last week, the Senate passed the 21st Century Cures Act by a vote of 94-5. The bill is headed to the White House where it is expected to be signed into law by the President.The Cures Act does many things for improving biomedical research and advancing clinical trials. Subtitle E,…
One question that comes up again and again in the healthcare industry is this: “Why do insurance providers deny based on a diagnosis not being listed in the final discharge summary?”In short, they should not be doing this at all. Under the Health Insurance Portability and Accountability Act of 1996…
EDITOR’S NOTE: This is the final installment in a two-part series on the enigma of sepsis. You can read Part I here.As I thought about writing this article, I was at first going to propose that we figure out a way to marry the old sepsis definition and coding schema with…
SPECIAL GUEST: Erica E. Remer, MD, FACEP, CCDS Founder and President Erica Remer, MD, Inc.GUEST CO-HOST Dennis Jones PFS Administrator, Nyack Hospital, Nyack, N.Y.

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The subject of the Zika virus continues to be in the news, particularly with the Nov. 9 announcement by the Centers for Medicare & Medicaid Services (CMS) that $66.1 million have been dedicated to Zika prevention and treatment.The American Hospital Association (AHA), through the Coding Clinic edition published for the…
Editor’s Note: With President-Elect Donald Trump nominating U.S. Rep. Tom Price (R-Ga.) to head the U.S. Department of Health and Human Services (HHS) and Indiana’s Seema Verma to serve as administrator of the Centers for Medicare & Medicaid Services (CMS), ICD10monitor Publisher Chuck Buck recently conducted an interview with Stanley Nachimson,…
When reviewing sepsis claims, all too often the primary focus is on searching provider documentation for signs and symptoms and/or clinical indicators that support the diagnosis of sepsis, or that support a query regarding the presence of sepsis.Many times the more subtle details in the sepsis guidelines are overlooked, and…
DITOR’S NOTE: This is the first in a two-part series on the enigma of sepsis.The term “sepsis” was coined by Hippocrates around 400 B.C., derived from the Greek word “sipsi,” which translates as “make rotten,” and it referred to the decomposition of organic matter. In the 19th century, Ignaz Semmelweis deduced…
Rudy Braccili, Jr., MBA, CPAM, CRCE; Kelly V. Canter, BA, RHIT, CCS, AHIMA Approved ICD-10-CM & PCS Trainer; Alice L. Fitts, RHIA, AHIMA Approved ICD-10 Trainer & Ambassador; Barbara Hinkle-Azzara, RHIA; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; and Melinda S. Stegman, MBA, CCS, AHIMA Approved ICD-10-CM/PCS…

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ExtStore.AdvPoll.initResult(); What have you been experiencing related to your Case Mix Index since the implementation of ICD-10? jQuery(document).ready(function() { var $wrapper = jQuery('.advpoll-wrapper-9'); $wrapper.find('.advpoll-answer-graph').each(function() { var $this = jQuery(this); $this.find('.advpoll-answer-line').width(0).animate({ 'width': $this.data('percent') }, 900); $this.find('.advpoll-answer-line-percent').width(0).animate({ 'width': $this.data('percent') }, 900); }); }); Overall our CMI has increased 15% Overall our CMI…
ICD10monitor and HRS recently collaborated to conduct a survey to assess where Talk Ten Tuesday’s listeners are positioned when it comes to Hierarchical Condition Categories (HCCs) in their workplaces. In line with the Talk Ten Tuesdays’ audience, the majority of the survey respondents were from the hospital setting. Our initial takeaway…
Unfortunately, I have been too busy of late to say much about the two new Coding Clinic editions, which came out nearly at the same time, due to being in the midst of preparing for the new ICD-10 codes that became effective Oct. 1. Certainly there are many that merit…
There is no shortage of uncertainty looming in Washington, D.C. regarding how things will unfold once President-Elect Donald Trump takes office.One of very few predictions that appear to be a safe bet, however, is that Rhonda Taller will be among the busiest people in the nation’s capital next year.The Talk…
Let me rephrase the title of the classic book Fear and Loathing on the Campaign Trail ’72, published around the time Nixon won reelection, to label this article Fear and Gloating on the Campaign Trail of ’16 (and please forgive me if I offend anyone; we psychiatrists sometimes say undesired…
November 28, 2016

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SPECIAL GUEST Erica E. Remer, MD, FACEP, CCDS Founder and President Erica Remer, MD, Inc.ALSO FEATURING Rudy Braccili, Jr., MBA, CRCE;
Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer;
H. Steven Moffic, MD; and Rhonda Taller, BA, MHA, HIMSS ICD-10 Task Force

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Palmetto GBA, a Medicare Administrative Contractor (MAC), will automatically reprocess Medicare Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) claims affected by the MS-DRG v34 Errata beginning Feb. 1, 2017.The recent announcement by Palmetto came on the heels of last week’s Medicare Learning Network MLN Matters…
In the first installment of this series of articles, Exasperation with Clinical Validation Denials (CVDs), I discussed what to do about such denials, which stem from legitimate concerns as to whether a condition is actually present for a patient. Honestly, I wish we had reserved that title for this final…
We always have an eye out for strategies that payers develop to avoid reimbursing providers for things they previously paid for routinely.I know there is a lot going on these days. While we were preoccupied with our kids starting a new school year, the World Series, the fortunes of our…
The insertion of nasogastric (NG) tubes is a common practice in most hospitals. As more facilities begin to capture and code this procedure, correct ICD-10-PCS code assignment is necessary. This article explores key details associated with coding the insertion of nasogastric tubes in ICD-10.Common Procedure for Many PatientsNG intubation is…
SPECIAL GUEST Joseph C. Nichols, MD Health Data ConsultingGUEST CO-HOST Holly Louie, RN, CHBME Healthcare Billing and Management Association ALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Sarah Laird, RHIA, CCS; Dennis Jones

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It’s so important that we in the healthcare industry continue our discussion regarding the topic of Hierarchical Condition Categories (HCCs), as the risk-adjusted payment models are increasing in prevalence.The assignment of HCCs and risk adjustment has extended beyond Medicare Advantage plans as a result of the Patient Protection and Affordable…
What could be most directly impacting reimbursement among hospitals and health systems? The problem could be, in many cases, the selection of principal diagnoses, since they drive the medical diagnosis-related groups (DRGs).For past 12 months, the health information management (HIM) consulting division at Panacea Healthcare Solutions has been conducting ICD-10 coding reviews among the nation’s…
With more than a full year under ICD-10, it seems it is reasonable to expect local coverage determinations (LCD) to be current and correct. After all, everyone in the industry knew there were errors and omissions in some national and local policies.Many had already been pointed out. And yes, some…
The coding landscape in physician practices is changing rapidly as healthcare moves toward value-based care and quality payment models. Medical practice coding for ICD-10 plays a key role in quality reporting under the new Quality Payment Program (QPP), which was recently solidified by the Medicare Access and CHIP Reauthorization Act…
FEATURING Rudy Braccili Jr. MBA, CPAM, CRCE; Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, RHIT, AHIMA Approved ICD-10-CM/PCS Trainer; Barbara Hinkle-Azzara, RHIA; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer; and Erica Remer, MD, FACEP, CCDS

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Often we talk about the patient care team and who makes up that special group of professional caregivers. We similarly look at the role that the coding professional plays in healthcare and with that team in particular. Certainly there can be clarifications made regarding the “direct” patient care team, and…
Two major rules published last month included major changes to the healthcare industry. First, the Centers for Medicare & Medicaid Services (CMS) issued its long-awaited Medicare Access and CHIP Reauthorization Act (MACRA) final rule on paying Medicare Part B providers for quality and performance. This new system, titled the Merit-Based Incentive…
It is very important to stay current with the latest coding guidance from official coding resources. Coding Clinic, published by the American Hospital Association (AHA), has released Fourth Quarter 2016. There are six key takeaways from this issue: Diabetes and Osteomyelitis: Previously, the official coding guidelines for this combination stated that…
While most legacy clinical documentation improvement (CDI) programs have been doing a good job at preserving revenue under the MS-DRG system, a potential blind spot exists. Value-based and alternative payment models (APMs) rely on the concept of risk adjustment to determine final payment in acute care. The Centers for Medicare &…
While most legacy CDI programs have been doing a good job at preserving revenue under the MS-DRG system, a potential blind spot exists as Value-Based and Alternative Payment Models rely on the concept of Risk Adjustment to determine final payment in acute care. The Centers for Medicare & Medicaid Services risk…
SPECIAL GUEST Melissa M. Martin, RHIA, CCS, CHTS-IM Chair of the AHIMA Board of DirectorsALSO FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified AHIMA Clinical Documentation Improvement Practitioner; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; and Stanley…

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This is the second installment in my series of articles addressing clinical validation denials. Clinical validation denials (CVDs) are the derivatives of diagnosis-related group (DRG) coding validation denials. The latter is a rejection of a claim on the basis of reviewing physician documentation and determining that the correct codes or…
With the specificity of ICD-10, it is important to use tools and technology to assist with coding. Computer-assisted coding (CAC) is one method that can benefit a practitioner, but can also harm them if it is not set up or used appropriately. Technology is only as good as it is programmed,…
All healthcare providers must now be (ICD-10) coding to the highest level of specificity. The ICD-10 flexibilities available during the first year of implementation are gone for physician billing.As of Oct. 1, 2016, all providers are required to code to accurately reflect the clinical documentation in as much specificity as…
“Sully,” the Clint Eastwood-directed movie about US Airways Captain Chesley “Sully” Sullenberger, played by Tom Hanks, recounts the dramatic emergency landing Sullenberger made on the Hudson River after his airliner’s two engines were disabled when struck by a flock of geese.While the newest commercial jets feature onboard flight-control computers, making…
Since August, scary clown activities and sightings started to escalate in the United States, and they have spread internationally. In response, McDonald’s announced that it was giving its clown mascot, Ronald McDonald, a break, and Target took some clown masks and costumes off the market.Some of these sightings have turned…
FEATURING Rudy Braccili, Jr., MBA, CPAM, CRCE; Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer; H. Steven Moffic, MD; Erica E. Remer, MD, FACEP, CCDS;
and Michelle Wieczorek, RHIT, RN, CPHQ

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When we look back on what we learned in our first year of ICD-10, it’s clear that some providers were and some were not fazed by the Oct. 1, 2015, implementation date. As I reflect on conversations with our customers (at MediRegs, we service customers across the spectrum, including but…
ICD10monitor’s resident psychiatrist, H. Steven Moffic, MD, who is also a popular guest on Talk Ten Tuesdays, recently received the received the Administrative Psychiatry Award from the American Psychiatric Association (APA) and the American Association of Psychiatrist Administrators (AAPA). The award was presented to Moffic on Oct. 6, during the fall…
Are you familiar with IBM’s supercomputer Watson? IBM’s stated aspiration is to make it “the world’s best diagnostician,” because it can store way more medical information than a human doctor and makes decisions based on evidence, free of cognitive biases. It is consistent, and, according to the company, “given the…
Providers nationwide have been scratching their heads for some time now over how to combat the increasingly problematic issue of clinical downgrading of diagnosis-related groups (DRGs) by auditors.Mount Sinai Health System in New York City might not have the solution – but it sure does have a game plan.The System’s…
Providers nationwide have been scratching their heads for some time now over how to combat the increasingly problematic issue of clinical downgrading of diagnosis-related groups (DRGs) by auditors.Mount Sinai Health System in New York City might not have the solution – but it sure does have a game plan.The System’s…

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October 19, 2016

HRS

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SPECIAL GUEST Erica E. Remer, MD, FACEP, CCDS; Founder and President, Erica Remer, MD, Inc.ALSO FEATURING Maria Bounos, RN, MPM, CPC-H, PMC, CSPO; Rudy Braccili, Jr., MBA, CRCE; Sandra L Brewton, RHIT, AHIMA-Approved ICD-10-CM/PCS Trainer; and Laurie Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10 CM/PCS Trainer

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I chose the titular subject for this article because many of us have been focusing on ICD-10-CM and PCS – and while CM is used by both inpatient and outpatient coders, we may have lost sight of CPT and HCPCS.CPT and HCPCS education is as important as ICD-10, especially considering…
Live reporting from the 2016 national convention of the American Health Information Management Association (AHIMA) continues today on Talk Ten Tuesdays, the weekly Internet radio program produced by ICD10monitor.In addition to the long-running regularly scheduled Talk Ten Tuesdays broadcast heard at 10 a.m. EST, two other broadcasts will air today, with…
The use of computer-assisted coding (also known as CAC) software is becoming more widespread in the coding industry, particularly in the coding of inpatient claims.It’s not a surprising trend, really, given the many known benefits of implementing a CAC system. Computer-assisted coding software helps streamline the coding workflow, reducing backlogs…

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The use of computer-assisted coding (also known as CAC) software is becoming more widespread in the coding industry, particularly in the coding of inpatient claims.It’s not a surprising trend, really, given the many known benefits of implementing a CAC system. Computer-assisted coding software helps streamline the coding workflow, reducing backlogs…
In my previous article, Aggressive Tactics by Third Party Auditors Should Make Providers Vigilant, I suggested that one of the actions to prevent unjustified clinical validation denials (CVDs) is to perform concurrent clinical documentation integrity (CDI) reviews and pre-bill audits. Permit me to expound on the role of CDI reviews in…
Live reporting from the 2016 national convention of the American Health Information Management Association (AHIMA) continues today on Talk Ten Tuesdays, the weekly Internet radio program produced by ICD10monitor.In addition to the long-running regularly scheduled Talk Ten Tuesdays broadcast heard at 10 a.m. EST, two other broadcasts will air today, with…
I chose the titular subject for this article because many of us have been focusing on ICD-10-CM and PCS – and while CM is used by both inpatient and outpatient coders, we may have lost sight of CPT and HCPCS.CPT® and HCPCS education is as important as ICD-10, especially considering the…
SPECIAL GUEST: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS Chief Operating Officer, First Class Solutions, Inc.ALSO FEATURING: Larry Field, Larry Field DO, MBA, CHCQM, CPC, CHC, LHRM; Andres Jimenez, MD; Laurie M. Johnson, MS, RHIA, FAHIMA; and Stanley Nachimson

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Hospitals paid under the Outpatient Prospective Payment System (OPPS) could receive a rate increase of 1.6 percent starting on Jan. 1, 2017, according to the proposed rules issued by the Centers for Medicare & Medicaid Services (CMS) on July 6, 2016.All integral, ancillary, supportive, dependent, or adjunctive services will continue…
Are you an organ donor? Before October 2005, I did not think much about this question. You may ask what happened in October 2005. My cousin had a heart transplant that month. He had been on the heart transplant list since October 1996. My cousin was 45 years old and…
EDITOR’S NOTE: National Hispanic Heritage Month runs from Sept. 15 through Oct. 15. In recognizing the healthcare contributions of Hispanics, ICD10monitor reached out to Andres Jimenez, MD. His story follows, as told to Chuck Buck.He naturally considered being a physician. His father was a surgeon in the Republic of Colombia…
EDITOR’S NOTE: During a recent Talk Ten Tuesday broadcast, listeners were asked “what percent of your claims are downgraded by third-party payers?” Downgrading by third-party payers occurs when the hospital-billed DRG is changed upon review by health insurance auditors to a lower-paying DRG. The majority of those who responded, over 51 percent,…
SPECIAL GUEST James Jones, MD Vice President of Administration and Senior Medical Director of CDQI Mount Sinai Health System New York, NY GUEST CO-HOST Maria T. Bounos RN, MPM, CPC-H, PMC, CSPO Wolters KluwerALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Laurie M. Johnson, MS, RHIA, FAHIMA; Laurie A. McBrierty, MLT,…

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The Centers for Medicare & Medicaid Services (CMS) has announced that the proposed rule for bundled payments (also known as episode payments) for high-quality, coordinated cardiac and hip fracture care modules will be targeted for initial implementation in 98 randomly selected metropolitan demonstration areas starting in July 2017. The full phase-in…
Prescription Opioid and Heroin Epidemic Awareness Week was observed from Sept. 19 -25, 2016. Prescription painkillers have taken the lives of more than 165,000 Americans since 1999. And even more lives have been lost globally.President Obama is asking for $1.1 billion in federal funding to address this healthcare and community…
For coders and clinical documentation improvement (CDI) specialists, the nuances and changes regarding coding superbug infections remain as dynamic as the pathogens themselves. Medication resistance, and especially antibiotic resistance, can be a challenging issue in the coding world.The bacteria in question include enterococcus, staphylococcus, klebsiella, acinetobacter, pseudomonas, and enterobacter. In…
There were no reports of major collisions on the I-10 Thursday, Oct. 1. Computer systems failed to crash and everything was pretty much business as usual for America’s healthcare system on a day some once thought might lead to a year of calamity. It didn’t happen. Remarkable for its absence of…
Modernmagic will work with you to create the best medical website solution for your specific needs. modernmagic.com
SPECIAL GUEST Sonya Manuel LPN, CCS, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer Jzanus Consulting, New YorkALSO FEATURING Rudy Braccili, Jr., MBA, CRCE; Sandra L Brewton, RHIT, CCS, CHCA, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer; and Laurie M. Johnson, MS, RHIA, FAHIMA, FAHIMA Erica Remer, MD, FACEP, CCDS

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The goal was to avert fraud, waste, and abuse.We all support that – we collectively pay for Medicare, and who likes throwing their money away?Let’s review the ideal: the patient receives excellent medical care, the provider does a good job documenting that care, the coder translates the documentation into codes…
Throughout the country, physicians have been taught to make sure that they capture all of the elements of history of present illness (HPI), review of systems (ROS), past family and social history (PFSH), and physical exam (PE). However, either they have not been taught or have failed to show that…