Revisiting Secondary Diagnosis Assignment: Part I
EDITOR’S NOTE: The following is the first in a two-part series on the Uniform Hospital Discharge Data Set. Assigning secondary or “other” diagnoses was a
EDITOR’S NOTE: The following is the first in a two-part series on the Uniform Hospital Discharge Data Set. Assigning secondary or “other” diagnoses was a
Twice a year, at the ICD-10-CM Coordination and Maintenance Committee meetings, new codes are discussed and proposed for implementation. Many organizations attend in person to
Many, many years ago, I was working on a clinical documentation (CDI) implementation project at an acute-care facility when I stumbled on what would be
Mumps has been in the news for several years, but is it really occurring more often these days? Mumps is a viral infection that affects
EDITOR’S NOTE: This article focuses on physician engagement and ICD-10 education. However, the term “physician” includes everyone licensed and credentialed to record a patient diagnosis,
With more than a year of ICD-10-CM/PCS experience under their belts, coding managers have begun to turn their attention toward fine-tuning coder education. They’re using
What does a doctor or other provider know about clinical documentation and integrity? What does a surgeon know? Why is it important? How do surgeons
It’s been a year since the “sepsis-3” definition was released at the Society of Critical Care Medicine (SCCM) meeting and concurrently published in the Journal
EDITOR’S NOTE: What follows is the second piece of a two-part series examining how health risk, severity, and complexity impact healthcare policy, payment, and quality
Coded data represents the foundational elements for healthcare decision-making, research, quality of care, monitoring of population health, pay for performance, payment, disease management, clinical registries,
Documentation should paint a picture of the patient’s condition. Medical necessity drives every patient encounter. In fact, the Comprehensive Error Rate Testing Program (CERT) states
EDITOR’S NOTE: What follows is the first of a two-part series examining how health risk, severity, and complexity impact healthcare policy, payment, and quality assessment.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24