Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?
This week's note from the instructor walks through the background of and processes involved in creating a Medicare Coverage Analysis document prior to billing for a clinical trial.
Q: If a patient is requesting his medical records via email, so long as our email is encrypted and secure, can we send it? We only have his email on his admission papers, which matches the email address he sent to us.
With 2020 underway, it’s a good time for facilities to review the standards set forth by the rules that define HIPAA regulations. Without a thorough understanding throughout an organization, it can be easy for violations to occur.
One of the most vexing challenges that CDI specialists have is how to engage physicians to completely and precisely document their patients’ conditions and treatments in the language required by ICD-10-CM, which is essential to risk adjustment.
Many healthcare organizations manage care for diabetes patients by prescribing medications and adjusting doses. But, increasingly, organizations like Geisinger Health System are paying closer attention to what goes on once the patient goes home and are helping to fill gaps that stand between patients and better health.
