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.
This week’s Medicare updates include a six-month enrollment moratorium for hospices and HHAs, a preliminary list of participants in the Ambulatory Specialty Model, and more!
Practices and revenue cycle management companies that report obstetric services must be ready to report under the new CPT guidelines for maternity care services by September 1.
