Accurate and detailed medical documentation is critical for patient safety and to ensure payment for services rendered. Use these tips to keep clinical trials documentation compliant.
Having access to the right information at the right time is critical for healthcare professionals, from patient access staff to surgeons, but when it comes to capturing sexual orientation and gender identity data, many organizations are still struggling to get it right. Use these expert tips to help your organization build a more complete, inclusive data set.
Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
An inpatient study recently published in the Journal of the Academy of Nutrition and Dietetics demonstrates the importance of accurate ICD-10-CM reporting for malnutrition to ensure accurate Medicare severity diagnosis-related group (MS-DRG) assignment and the establishment of appropriate comparison benchmarks such as expected geometric mean length of stay (GMLOS).
Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. This does not reduce the payment for the drugs, so this is an informational modifier, but it is a mandatory modifier.
Learn how to emphasize the clinical value of the documentation and establish policies and training that support medically and legally sound notes while making the best use of physicians’ time.
Establishing an outpatient CDI program can have substantial benefits. Recently, an outpatient CDI review project demonstrated there were many documentation improvement opportunities at a large family practice/internal medicine physician clinic.
Experts Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS review the recently published “Global Leadership Initiative on Malnutrition (GLIM) Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community” and help coders apply this criteria in ICD-10-CM.
