Documentation is integral to solving this problem. UnitedHealthcare (UHC) recently threatened to implement a new policy wherein they would be retroactively denying some emergency department claims for their commercial members if an internal evaluation suggested that the services were not emergent. Anthem has had a similar policy in place since…

Comfort care is not an indication to stop documenting and coding. Last week, a listener reached out to me to ask me my opinion on querying for potential comorbid conditions or complications in relation to patients who expire. Specifically, she pinpointed patients who were transitioned to comfort care and asked…

Documentation by association. My home office is located in Merritt Island, Florida, and if you’re not familiar with where that is, you’re not the first. It’s actually five miles from Kennedy Space Center, which is about 40 miles southeast of Orlando. I moved into a home office about eight years…

EDITOR'S NOTE: This article was originally published online last week, but following review by members of the editorial board to correct minor factual errors, it has been revised and republished.  IntroductionThe COVID-19 pandemic has brought about robust changes to the traditional practice of healthcare in the United States. In a time…

Late physician signatures pose serious issues. In the last few months, I have had questions about late signatures on documentation come in from several clients. I've been hearing about providers signing their notes a very long time after the encounter – sometimes weeks later, sometimes months,  and sometimes even turning…

All bad documentation is based on lies – the lies doctors (and all human beings) tell themselves. We always believe our lies, because they are how we construct a false reality that makes our bad behavior seem acceptable to ourselves. Theologians might call it original sin, humanists might call it…

Understanding why a culture of compliance in coding and documentation is so important. Compliance is a large part of our duties in healthcare. It is especially true for coding. With so many regulations, the audit atmosphere and payment nightmares, quite simply we are a moving target. For those of us…

As the provision of healthcare changes, so too must clinical documentation improvement. I have always been convinced of the strong capabilities of current clinical documentation integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record. Today’s…

New program for live CDI education is gaining traction. Last week, I shared details about a new activity I have been doing with a client that I think is extremely beneficial, and suggested that perhaps others could implement a similar program in their own practices. I was asked to lay…

New CMS document features gems that fill risk adjustment voids for coding rules. Coders love rules. In risk adjustment coding, we live by the Official Guidelines for Coding and Reporting, the ICD-10-CM conventions for code lookup, and the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS. Too often, though, we run…