The aftermath of Florence prompts a review of emergency preparedness We know the 2018 hurricane season is upon us, but we are always unsure of where the individual storms will appear, what their track will be, and how they will behave. Hurricane Florence—since downgraded to a tropic depression— has been…

New code changes number 335. The new current procedural terminology (CPT®) codes have been released with 335 code changes in 2019.  There were many code revisions with guideline, description and instructional note changes.   Let’s look at the highlights of many new CPT codes for 2019. There six new codes in the…

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…

Physician documentation issues during an audit go beyond CDI. The issues are the chief complaint and HPI. Editor’s Note: This is the second piece in a four-part series that examines physician documentation issues as seen by an auditor. As I discussed in the first portion of our series on physician…

The new classification is designed as a database and has up to 13 dimensions. The World Health Organization (WHO) will be releasing the 11th Revision to the International Classification of Diseases, or ICD-11, this May. The WHO and many of its 194-member countries have been working on this since 2007.…

Unfortunately, the quality of data is driven less by opportunity and more by incentives for those creating the data.Prior to the implementation of ICD-10, the key selling point of the new coding set was that it provided the opportunity for more detailed data about the nature of each patient’s condition.…

In order to make healthcare effective, safe and affordable, clinical organizations must ensure complete and accurate clinical records.In preparation for my remarks on the Talk Ten Tuesdays broadcast of Oct. 31, 2017, I reviewed my own time served on this topic. I also reflected on the many people I’ve met…

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…