How to Make the EHR More Effective

Make your documentation tell a story that makes sense to the reader. I have been talking about improving the electronic medical record and making it

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Improving Access to Specialists

New rule allows Medicaid and CHIP programs to pay specialists directly when a primary-care provider requests their advice. New guidance issued Jan. 5 by the

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CDI and Compliance: The Offense of Being Naked

Diagnosis without supporting the judgment of the physician’s documentation is the phenomenon of nakedness. A recent Association of Clinical Documentation Integrity Specialists/American Health Information Management

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Is There a Doctor in the House?

A physician laments that physicians were not invited to participate in the AHIMA/ACDIS CDI Practice Brief. For steadfast readers of ICD10monitor and attentive listeners to

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When a Home is Not a Home

There are some key 2023 CPT® Evaluation and Management (E&M) Code changes for Home and Residence Services. EDITOR’S NOTE: The American Medical Association (AMA) announced

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AHIMA Releases New Guidelines for Queries

The updated guidelines were developed jointly by AHIMA and ACDIS. The American Health Information Management Association (AHIMA), in collaboration with Simplify Compliance’s Association of Clinical

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