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.
Medicare billing edits such as National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUE) must be resolved at their root cause so that they do not continue to occur on claim
Q: I work for a hospital with a geriatric psychiatry unit. Many patients are discharged to nursing homes. Often, nursing homes contact the hospital for patient information, but we have only the patients' psychiatric records and are hesitant to send them. Is it permissible under HIPAA to send this information to a nursing home for continued care?
SamSam ransomware is the cause of eight cyber-attacks that have affected government and healthcare organizations this year, according to an HHS report. SamSam ransomware attacks began in 2016 with instances of the encrypted “.weapologize” extension infecting at least 10 entities since December 2017.
The vast majority (94%) of IT decision makers report having concerns about moving data to the cloud, despite the increasing shift to software as a service usage.
Information for 63,551 patients for Middletown Medical, a multispecialty physician group in Middletown, New York, was exposed due to a misconfigured security setting on a radiology interface.
Providers should be preparing for another rulemaking cycle from CMS as we hit April, with the IPPS rule expected to include a discussion on how the existing payment system can address new and emerging cellular and gene therapies.
CMS held a listening session March 21 to gather input from stakeholders on potential updates to the E/M documentation guidelines. The current guidelines are considered outdated in light of medical advances and the advent of the electronic health record.
