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…

More than half of physicians have experienced burnout, according to WHO. The World Health Organization (WHO) has classified physician burnout as an occupational phenomenon.     The WHO is clear that this is not a medical diagnosis. There are some estimates that more than half of physicians have experienced burnout. This…

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,…

Contest indicates coding accuracy is below expectations. Central Learning is a web-based coding assessment and education application. Since 2016, the company has conducted an annual national coding contest to measure ICD-10 coding accuracy and production. The initial premise was to evaluate how coding accuracy and production work, compared to ICD-9.…

Documenting challenges with EHR usage. Last week, I started telling you about a Law-Medicine combined conference I attended through Case Western Reserve University School of Medicine about EHRs and Safety concerns. I am going to continue with the speakers and review the assigned readings. The speakers referred to, and the…

“Virtual" peer reviews are a covered benefit for most payers. In keeping with our theme of “communication-based services,” let’s take a closer look at the inter-professional consults and referrals that do not include a face-to-face encounter with a patient. Some are existing CPT® codes, and two new codes, in this…

Documenting challenges with EHR usage. At the beginning of the month, I attended an interesting conference through Case Western Reserve University School of Medicine called, “Electronic Health Records and Patient Safety: Legal Challenges and Solutions.” I am going to unpack it for you in a two-part series. I have included…

AI-powered solutions must align with applicable coding guidelines. Electronic health records (EHRs), clinical documentation software, and enabling technologies are working together in new and exciting ways to create accurate, robust, and concurrent patient documentation that improves quality of care while protecting healthcare organizations’ financial integrity. But as I wrote last…

National healthcare entities are teaming up and speaking out on how to make healthcare better. EDITOR’S NOTE: The following was discussed by Nachimson during last Tuesday’s Talk Ten Tuesdays live broadcast. There are two major and complementary rules to advance interoperability being proposed by U.S. Department of Health and Human…

Is the healthcare industry tone deaf to physicians’ complaints? The Physicians Foundation 2018 Physician Survey, published on Sept. 18, 2018, features opinions of our nation’s physicians—opinions that are sobering and should sound a loud wake-up call.  When distilled down to the very essence of the report, the “fixes” for our…