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.
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.
Coding for alcohol- and drug-related disorders requires careful attention to both clinical terminology and the structure of the ICD-10-CM classification system.
