The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…
Does your staff know what is involved in taking a complete history from a patient?
The ICD-10 page on the Centers for Medicare & Medicaid Services (CMS) website features a countdown clock that shows the time left until Oct. 1, 2015, the date on which compliance with the new code set becomes mandatory. By the time this issue goes to press, the clock will read 90 or fewer days. Time…
The operations management team in healthcare practices is expected to have an effective coding compliance program in place that is continually evaluated and reevaluated. To accurately assess the program’s effectiveness, several outcome indicators must be measured, including error rates in the provider’s documentation and the electronic health record (EHR). Due to increased scrutiny by the…