Documentation improvement

Use these tips to avoid common TKA coding and documentation pitfalls.

Most inpatient rehabilitation facility stays might not meet Medicare coverage or documentation requirements and compliance could be improved through a preauthorization process, according to a recent Office of Inspector General report.

Developing an outpatient CDI program isn't just about metrics--departments needs to consider how to engage providers and interact with other teams to be truly effective.

Q: How can we help our physicians improve their documentation of medical necessity?

Competing perspectives and priorities can lead CDI programs down the wrong path. Understand how differences in professional backgrounds and approaches to documentation can cause conflict in CDI.

Learn about how providers can adhere to the latest regulations and guidance when coding and reporting chronic care management.

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.

Follow these tips to ensure providers ace chronic care management documentation requirements.

CMS recently released new documentation guidance on medical review of E/M services performed by medical students. A medical student may document E/M services if the physician performs or re-performs the exam and then verifies the student’s documentation.

The fiscal year (FY) 2019 ICD-10-CM code update, released on June 11, includes 279 code additions, 143 revisions, and 51 invalidations. The number of changes is significantly less than the past two years, which makes me think we are getting back to the “norm” of expected yearly changes.