Letters to the Editor

I remember in my training as a medical student, one day as I obsessively wrote down and documented (to a degree that would probably be required today), a wise resident pulled me aside and asked, “What is the name of this section in the chart?”

“It is the progress note section,” I responded.

“Well, do not put anything in there unless there is progress,” the resident said.

I suspect if Dr. Stead were alive today he might modify his famous saying to, “What this patient needs is a doctor—not a document.”

Jeffrey W. Wilson, MD, MBA
Lynchburg Rheumatology Clinic,
Lynchburg, Va.

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…

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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…

The ACR has compiled guidelines and tips on how to use the JW modifier and correctly bill Medicare for discarded drugs and biologicals. This modifier can be applied only to unused amounts from a single-dose vial or package.

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Letters to the Editor

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