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.
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.
Payers rely heavily on the use of data and data analytics to manage their risk. Follow these tips for using payer guidelines to understand what they’re looking for and how to improve 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.
