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,…
Meanwhile, the House of Representatives holds a hearing on the topic. Although the U.S. House of Representatives has seemed preoccupied with other issues in Washington D.C., it also recently held a hearing on H.R. 1384, the “Medicare for All Act of 2019.” This bill was introduced by Rep. Pramila Jayapal…
Coders need to know when and how the cardiac arrest occurred. There are approximately 350,000-400,000 cases of cardiac arrest arising outside of the hospital setting per year, and not all of these patients make it to the emergency department. The incidence in any given hospital on any given shift is…
The aim of documentation is to tell the true story. Last year, I wrote a two-part series on clinical documentation integrity, specifically focusing on the emergency department (CDI in ED Part I; CDI in ED Part II). Today I will focus on how ED documentation supports medical necessity of investigative…
The query process is no substitute for education and training.The hallmark of any true clinical documentation integrity (CDI) program consists of medical record chart review by clinical documentation integrity specialists (CDISs) with a goal of identifying gaps in diagnosis specificity as well as addressing other deficiencies requiring clinical clarification. Some…
Three key takeaways from this effort by healthcare giant UnitedHealthcare UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the…
Amid the chaos of the ED, order is needed.EDITOR’S NOTE: This is the final installment in a two-part series on clinical documentation integrity (CDI) in the emergency department (ED).It is my opinion that investing CDI resources into the neglected stepchild that is the hospital system ED is a worthwhile endeavor.…
A Talk Ten Tuesdays listener weighs in on woefully insufficient documentation of a routine visit.EDITOR’S NOTE: During last Tuesday’s Talk Ten Tuesdays broadcast, a listener who prefers to be called “Robert” sent an email message to us describing his recent experience as an emergency department (ED) patient – after which…
The mass shooting in Las Vegas has prompted renewed attention on emergency medicine and trauma care and especially on the clinical documentation of care in this setting. I practiced emergency medicine (EM) for twenty-five years before I transitioned to being a physician advisor. My expertise had been in the professional…