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EDITOR’S NOTE: The Current Procedural Terminology (CPT®) changes for 2023 were released on Sept. 12. This release from the American Medical Association (AMA) includes 225 new codes, 75 deletions, and
The process involves a multi-step review. Physicians take the Hippocratic Oath in medical school to “do no harm.” Despite their best intentions, however, many physicians sometimes unwittingly trigger a patient safety
The series begins today on Talk Ten Tuesday with ChristianaCare. The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency under the U.S. Department of Health and
Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety. As a clinical documentation integrity (CD) I
Unfortunately, the problem list is organized the way it is. The problem list is a problem. We talk about this, but I think we don’t explore why it is such
Providers should never C&P material they have not read nor vetted for accuracy. A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his
Problem lists are a problem because often they are not updated. Over the last year, we have heard much about Medicare Advantage (MA) health plans being investigated or fined by
Efficiencies increase health system revenues. Major shifts in the healthcare landscape over the last 10 years have substantially impacted hospital system reimbursement. Placing an ever-greater importance on documentation accuracy and
What can medical assistants (MAs) do and not do? Medical assistants (MAs) have a narrow list of things they can do for patients or a physician in a doctor’s office.
Documentation is integral to solving this problem. UnitedHealthcare (UHC) recently threatened to implement a new policy wherein they would be retroactively denying some emergency department claims for their commercial members
Comfort care is not an indication to stop documenting and coding. Last week, a listener reached out to me to ask me my opinion on querying for potential comorbid conditions
Documentation by association. My home office is located in Merritt Island, Florida, and if you’re not familiar with where that is, you’re not the first. It’s actually five miles from
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