Q: Payers have been pushing back when a diagnosis appears in the discharge summary and not in the chart. Can the physician add a late entry or addendum into the medical record by way of a progress note or an addition to a discharge summary...Read More »
We, in the United States, will soon need to adopt the electronic health record (EHR). Over the past few years, of course, healthcare entities have slowly converted from the traditional handwritten medical record toward one that is totally digital. There have...Read More »
Shortly after releasing its Clinical Documentation Improvement Toolkit in April, the American Health Information Management Association (AHIMA) released its Guidance for Clinical Documentation Improvement Programs in the May issue of the Journal of AHIMA.
ACDIS Associate Editorial Director Linnea Archibald sends out “missed connections” emails with questions from Council members on a regular basis. Anyone with experience related to one of the questions was invited to respond and Archibald connected them with the question-asker. In order to share...Read More »
CMS has been holding a number of open forum calls regarding its Recovery Audit Contractor (RAC) programs. Dubbed “Nationwide RAC 101 Calls” these sessions covered the basics of RAC reviews, each focusing on a different provider area.
The first call on April 28, intended for all acute...Read More »
Effective January 1, 2011, CMS will start to accept up to 25 codes for secondary diagnoses. The change, listed in a March 2010 MedLearn Matters article and also listed in the...Read More »
