The American Medical Association (AMA) recently published a checklist to help physician practices transition to the new evaluation and management (E/M) coding and documentation guidelines slated to take effect January 2021, JustCoding reported.
by Linnea Archibald
Since the United States reported its first case of the novel coronavirus (COVID-19) in early January 2020, things have changed at a daily pace. At the time of this edition’s publishing, there have been more than three million COVID-19 cases worldwide and more...Read More »
by Laurie L. Prescott, RN, MSN, CCDS, CCDS-O, CDIP, CRC
It’s springtime! Daffodils are sprouting, birds are nesting, and our first quarterly Coding Clinic has arrived. Generally, the first release of the year is packed full of direction, and this issue did not disappoint...Read More »
Getting clinical conditions appropriately documented is not a new problem in medicine, especially in pediatrics. This is particularly true for conditions where a universally accepted clinical definition does not exist, such as heart failure for pediatric patients. This has led individual...Read More »
A new year often spells change for CDI programs looking to extend their influence in their organizations. With the rise of health systems over independent hospitals, many CDI teams find themselves reviewing records outside of the traditional acute care...Read More »
We’re having a lot of discussions lately on whether we should query for pressure injuries when they’re only documented by nursing. Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our...Read More »
In recent years, clinical validation has become a prevalent topic in the CDI field. According to Elizabeth Aguirre, MD, CCDS, CDI program physician lead at Baylor Scott and White Medical Center in Temple, Texas, the increased focus is at least partially the result of common...Read More »
