Correct, complete documentation is the foundation of a sound medical record and compliant reimbursement, but getting that foundation in place can be challenging. Clinicians are juggling critical tasks in a high-stress situation, and administrative burden of electronic documentation and the disconnect that results from spending more time looking at a screen than a patient are often cited as the primary factors in physician burnout. Enter the medical scribe.
Success under MACRA relies on the capture and maintenance of trustworthy clinical and financial patient data sets. HIM professionals understand root cause analysis, the mechanism of reporting data, and the importance of data consistency and integrity.
Creating and using performance standards benefits HIM directors and the many functions they oversee. But with such a wide range of tasks falling under the HIM umbrella, it can be challenging to set practical standards that yield meaningful results. Follow these tips to get the most of out of your department’s standards.
The brain is the most complex component of the central nervous system, consisting of approximately 100 billion neurons that communicate via an exponential number of synapses. Coding for the brain can seem almost as complex. Brush up on ICD-10-CM/PCS coding for the brain.