Coders are an often-overlooked member of the healthcare team. But without their expertise, both the patient and practice would suffer.
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You are probably very familiar with the phrase: “If it’s not documented it never happened.” In healthcare you should live by it, because clinical documentation is the core of every patient encounter for every medical institution.
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Recent technological advancements have changed the way we see things, paving the way for the growth of concepts such as telemedicine, or telehealth, in the field of medical technology. Telehealth is a method of providing clinical healthcare to someone from a distance, by the use of telecommunication and information technology.
Read MoreIn today’s connected world, almost everyone has heard the term HIPAA, or Health Insurance Portability and Accountability Act, and has some idea that it’s related to healthcare privacy. However, some entities tout themselves as being HIPAA Certified. What does that mean, especially to a company looking for this type of certification?
Read MoreThe ICD-10 frenzy came and went. Armageddon type reparations were made for the major overhaul ICD-10 brought about. Employers hired extra coding staff in preparation of possible delays while coders adjusted to the higher levels of specificity. Now ICD-11 is coming and preparations have begun. Let’s look at what ICD-11 will bring and how you can be part of the upcoming changes.
Read MoreWe can all learn the definition of Modifier 25, “Significant, separately identifiable evaluation and management [E/M] service by the same physician or other qualified health care professional on the same day of the procedure or other service,” but do we really understand the meaning of it?
Read MoreImplemented on March 5, 2018, CMS relaxed the teaching physician guidelines to allow for broader usage of medical student documentation. Previously, CMS restricted student documentation to solely recording the review of systems (ROS) and past medical, family, and social history (PFSH). The teaching physician would need to document or re-document any other aspects of the visit. The update allows the teaching physician to utilize the student’s documentation of the entire visit.
Read MoreDid you know there’s a competition to determine the “best” coder? The 2nd Annual ICD-10 Coding Contest took place July 14 - August 11, 2017. Central Learning sponsored the coding competition and recruited coders from all over the nation to participate in coding a total of 1,636 real medical record cases. Ninety-nine percent of the participants were certified coders. The inpatient coders who participated had an average of 14.3 years coding experience while the outpatient coder experience averaged 9.9 years.
Read MoreThe healthcare industry is maturing to meet the demands of the country’s aging population. As Americans grow older, they consume more healthcare services. Not surprisingly, the U.S. Bureau of Labor Statistics reports medical coding is expected to grow by 15 percent in the coming years.
Read MoreCapturing maximum E/M revenue should always be the goal while coding major surgeries and modifier 57 can help.
Read MoreICD-10 mirrors Y2K; speculation and anxiety surrounding new changes and the unknown. Just like Y2K, we all survived without catastrophic meltdown.
Read MoreWhether you're facing a backlog associated with growing lag days or discharged not final-billed (DNFB), you're preparing for an Electronic Health Records (EHR) conversion, expanding your service line, or there are geographic obstacles preventing you from finding all the internal coding resources you need... outsourcing can be the answer you're looking for.
Read MoreHave you ever wondered how to capture appropriate levels of evaluation and management when counseling or coordination of care dominates the majority of a visit? There are some simple tips to remember when billing time-based EM codes.
Read MoreThe holiday season is upon us and for those of us in Health Information Management (HIM), added stress is a given because HIM is the single most critical process in the revenue cycle.
Many facilities strive to finish the year with strong cash reserves, so December often brings added pressure to HIM professionals, responsible for controlling the cash flow and answering to CFOs, who keep a close eye on the Discharged Not Final Billed (DNFB) report.
Read MoreAs it does every year, the Center for Disease Control (CDC) has released the top ten causes of death in the United States.
The 2015 list by incidence and prevalence:
Read MoreThe 2017 ICD-10-CM is looking a bit more like ICD-9-CM thanks to the addition to some codes that were forgotten in the first release. As a heavy user of external cause codes and an ED coder at heart, I was so accustomed to using the E927 series that when ICD-10-CM came out I felt lost and forgotten. They may have forgotten the highly used code series; but fear not, they remembered them this year.
Read MoreAs coders we face many struggles, including determining when the use of modifier 25 is appropriate.
Modifier 25 was designed to indicate a significant, separately identifiable evaluation and management (EM) service, by the same physician/specialty on the day of a procedure with a global period of 0/10 days. What can be challenging is knowing when to apply the modifier correctly.
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