Interoperability is seen as the first step to using data for health improvement. I expect that 2019 will be the “Year of Interoperability”.  The Centers for Medicare & Medicaid Services (CMS), through its hospital and physician incentive programs, is asking providers to have their electronic health records (EHRs) capable of…

How healthcare providers can best prepare for the worst. Editor’s Note: The following is a transcript of a recent segment on Talk Ten Tuesdays by Julie Dooling, speaking on challenges and tips for healthcare organizations in the face of a natural disaster. Collectively, we continue to learn from experiences where…

Two recent studies report on the alarming rate of physician burnout. EDITOR’S NOTE: Physician burnout, a topic of great interest across the healthcare industry during recent years, continues to make headlines.Talk Ten Tuesday host and ICD10monitor Publisher Chuck Buck and renowned psychiatrist H. Steven Moffic, MD discuss the topic. What follows is…

The lesbian, gay, bisexual, transgender, and queer (or questioning) (LGBTQ) population faces barriers to appropriate healthcare access. EDITOR’S NOTE: The American Health Information Management Association (AHIMA) has developed a practice brief on this issue, and ICD10monitor will continue to report on how recognition of this vulnerable population is being demonstrated…

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.…