Editor’s note: Cesar M. Limjoco, MD, and Kelli A. Estes, RN, CCDS, will be presenting “The ultimate test for queries,” on Day 1 of the ACDIS conference. Limjoco is the vice president of DCBA, Inc. in Indianapolis, Indiana....Read More »
The use of electronic health records (EHR) should be guided by ethical principles that put patient care at the forefront, according to a position paper published by the American College of Physicians (ACP). EHRs can be an...Read More »
Q: Lately, we have been receiving responses of “did not assess or treat” or “this is a chronic stable medical problem not associated with the patient’s presentation,” although the nutritional assessment such as severe malnutrition is...Read More »
Q: If a consulting physician documents a diagnosis related to his or her specialty but the attending does not (instead simply documenting, “thank you for your assistance”) can the consulting physician’s documentation be used for coding purposes? My most experienced associate says we can...Read More »
