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.
Many HIM directors find that managing the coding team requires a different type of focus than other functions within the department. This may be true because coding professionals have advanced education, prefer a quiet work environment, and require less direction.
Although regulatory agencies have not banned the use of medical scribes, organizations must follow certain requirements. Learn how to define the scribe’s role and responsibilities and ensure that documentation is correctly certified.
The nearly 30-year-old Stark Law could be due for an overhaul, according to CMS. The agency is requesting public feedback on how to streamline the law’s administrative requirements and retool it to better fit with modern alternative payment models and value-based care.
The Hierarchical Condition Categories (HCC) risk-adjustment methodology is beginning to surface more frequently in both the acute and primary settings. Use these expert tips to help improve complete, compliant HCC capture.
When evaluating a code edit, it’s necessary to understand exactly when or where in the claim or billing process the edit arose. Look to coding guidance to help edit resolution efforts.
Although compliant querying is clearly spelled out in inpatient CDI, where patient encounters can last three to five days, it’s more complex in the fast-paced ambulatory world where single patient encounters are shorter and may be spread over a year’s time. Experts weigh in on the best approach to effective, compliant outpatient queries.
The Government Accountability Office (GAO) has urged CMS to renew prior authorization programs slated to expire. The GAO made its case for continuing the programs in a report released in April, arguing that the programs reduced spending by nearly $2 billion since 2012.
CMS recently clarified the use of modifier -KX (requirements specified in the medical policy have been met) in response to an Office of Inspector General report that identified conflicting guidance that resulted in $4.6 million in improper payments.
The brain is the most complex component of the central nervous system, consisting of approximately 100 billion neurons that communicate via an exponential number of synapses. Coding for the brain can seem almost as complex. Brush up on ICD-10-CM/PCS coding for the brain.
