Documentation improvement

A recent case centered on the misuse of evaluation and management (E/M) codes in emergency department billing offers valuable insights for HIM professionals.

Analyze the clinical, diagnostic, and coding challenges associated with documenting substance use, abuse, and dependence.

Learn about how a large health system's CDI program approaches risk adjustment in the outpatient setting. 

Explore proper coding and documentation practices for acute respiratory distress syndrome (ARDS).

Learn about the robust overhaul of lymphoma diagnosis codes in the latest ICD-10-CM update.

CDI staff must be able familiarize themselves with missing clinical indicators that commonly lead to denials.

Review education strategies for CDI professionals to improve documentation, reduce denials, and boost accuracy in medical records.

When an office/outpatient visit is coded based on time, think beyond face-to-face time to get full credit. This article reviews time-based coding, how to count time, which activities count toward time, and which ones don’t.

Analyze how using more technology to carry out various clinical documentation integrity (CDI) functions could impact your organization.

Review recommendations and tips for attending physicians regarding the incorporation of CDI principles into medical student documentation education.