EHRs - ICD10monitor
EDITOR’S NOTE: Dr. Erica Remer reported this story live during the Dec. 3 edition of Talk Ten Tuesday. The following is an edited transcript of her reporting. A Medscape survey popped up in my email a few weeks ago. The title was, “Is Technology Replacing Patient History?” (https://www.medscape.com/viewarticle/921235) and it linked…
November 26, 2019
Change is Coming for E&M: Start Preparing Now for 2021
E&M codes are the most frequently used codes in any physician practice. Change is coming to the world of evaluation and management (E&M) services. With the Physician Fee Schedule Final Rule for 2020 now published, we know there are big changes to be expected in 2021. The good news is…
November 26, 2019
HCC Coding: Preparing for ICD-11
HCCs thrive on specificity and ICD-11 will provide a higher level of specificity than in ICD-10. For those of you who are coding for hierarchical condition category (HCC) purposes, you know that HCCs are categories of related ICD-10 codes. Only selected significant conditions to drive a payment HCC. That means…
November 19, 2019
New Changes to Coding Pressure-Induced Deep Tissue Damage in 2020
Providers should review their protocols to prepare for the changes. The 2020 updates to ICD-10-CM contain some significant changes to Chapter 12, Diseases of the Skin and Subcutaneous Tissue. These changes include the addition of new codes for the reporting of pressure-induced deep-tissue damage, also known as deep-tissue pressure injury…
September 24, 2019
With late signatures, can you still bill for your medical services?
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…
June 4, 2019
Physician Burnout: A Hot Topic
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…
May 21, 2019
Lessons Learned from Consulting: Institutional Improvement of ED Clinical Documentation
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.…
April 23, 2019
Electronic Health Records and Patient Safety: Lessons Learned from Law-Medicine Conference: Part II
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…
April 23, 2019
Non Face-to-Face Services: Part II
“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…