Providers should have the choice of bringing into the record what they deem to be relevant and important. I am currently doing a project assessing emergency physicians’ documentation from disparate sites, and I am finding that they each have a different electronic health record (EHR) and/or template. Some are pleasing,…

Coding of chronic conditions: Part 2  This article addresses concerns regarding the coding of chronic conditions during a patient’s journey. The truth of the matter is that depending on your role in the coding process, your experience coding chronic conditions can differ greatly from that of others. As indicated in…

Trends in Clinical Documentation, Past, Present, and Future – Part I For nearly a century, since Grace W. Myers of Massachusetts General Hospital became the first medical records librarian in the early 1900s and the American College of Surgeons (ACOS) sought to improve the standards of medical records being created…

Clinical documentation will need to reflect these situations in order to be accurately coded. When beginning research for this article, I opened my 2018 ICD-10-CM book to the External Cause Index section, specifically for the word “harassment,” but it was missing.     The next area I reviewed was the Index, but…

Some providers hesitate to use the word “abuse” preferring, instead, to use non-accidental trauma (NAT). Despite what revenue cycle may believe, clinical documentation is not solely for billing. One of the biggest problems with imprecise, nonspecific diagnoses which lead to unspecified codes or, even worse, index to no codes at…

Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you? Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor. As we dive even further into the auditing pitfalls of a physician E&M audit,…

“Ebony and ivory live together in perfect harmony  Side by side on my piano keyboard, oh Lord, why don't we?”— Sir Paul McCartney and Stevie Wonder, 1982   Left alone in a small examining room, I scrolled the Associated Press news app on my cell phone, waiting for my physician to…

Recently I reviewed a case that triggered an exposition. As a clinician, I am always trying to wrap my head around a coding-clinical disconnect in the ICD-10-CM Official Coding and Reporting Guidelines regarding poisoning versus adverse effects. All medications have side effects; a clinician considers the cost-benefit ratio of each…

CDI programs are viewed by most physicians as hospital-led initiatives geared towards increasing reimbursement for the hospital.The majority of clinical documentation improvement (CDI) programs fail to effectively engage physicians as willing participants in the push to accurately capture patient care provided through clear, concise, and contextually consistent reporting. Clinical documentation…

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…