Solid Documentation for Medical Decision Making in E/M: Ensure Your Providers Get a GOLD Medal and Not a “Participation” Trophy Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, CCDS-O, director of HIM and coding at HCPro in Middleton, Massachusetts....
Provider organizations are increasingly adopting computer-assisted physician documentation (CAPD) and artificial intelligence (AI) for Clinical Documentation Integrity, providing physicians with efficient, real-time support as they document in the EHR.
No matter how much the CDI industry grows, physician education and engagement remain one of its top concerns. A lack of physician buy-in will stymie even the most rigorous CDI efforts. While the problem remains front and center, CDI teams now have significantly more tools by which to tackle it....
The twin trends of patients using quality data to choose where to go for care and the popularity of value-based care purchasing programs to manage healthcare costs will only continue to grow. Healthcare organizations understand that if they can impact their quality scores, they are more likely...
We do many queries for malnutrition and are looking for a better way to get this essential diagnosis into the medical record without a query. I...Read More »
