The Office of the Inspector General announced it is launching a new audit of evaluation and management services billed on the same day as minor procedures.
It is no longer enough to confirm that a diagnosis is documented somewhere in the record. The documentation must also clearly demonstrate the clinical severity of the patient’s illness.
Coding for alcohol- and drug-related disorders requires careful attention to both clinical terminology and the structure of the ICD-10-CM classification system.
As artificial intelligence (AI) moves deeper into healthcare operations, from clinical documentation to coding and decision support, HIM leaders are being pulled into a more central, critical role.
