The adage frequently cited in healthcare settings, “If it isn’t documented, it wasn’t done,” still rings true for the key components required in a patient’s medical record. The note in the medical record must sufficiently describe all of the services furnished to patients on a specific date. The essential requirements to appropriately bill a claim…
Take the challenge. B—The presenting problem(s) is what is evaluated during the history and examination by the provider. The chief complaint is in the patient’s own words or is a follow-up for his or her current condition. The history of present illness, along with the review of systems, usually guides the provider through the examination….
Evaluation & Management Documentation Quiz What element drives an evaluation and management (E/M) visit? The chief complaint in the patient’s own words of why he or she is in the practice for that date of service. The presenting problem(s) being discussed with the physician for that patient during the visit. The examination performed on the…
The ACR’s Collaborative Initiatives (COIN) department develops and tests innovative solutions for complex rheumatology care problems. “All of the work COIN does—programs toward health equity, creating models to increase rheumatology-related capacity in places of need, building bridges with local and national patient organizations—is done on [behalf of its members],” says Dr. David Daikh. Each month…
You can now use the updated Centers for Medicare & Medicaid Services (CMS) MIPS Participation Lookup Tool to check on your 2018 eligibility for the Merit-Based Incentive Payment System (MIPS). Enter your National Provider Identifier (NPI) in the tool to find out whether you need to participate during the 2018 performance year. Changes to…
Join us in Chicago for the 2018 ACR/ARHP Annual Meeting on Oct. 19–24. Register now to save; advance registration rates end Oct. 3. High-Impact Learning Starts with Pre-Meeting Courses Pre-meeting courses offer attendees unique learning opportunities in specific topic areas. The pre-meeting courses will be held at McCormick Place Oct. 19–20. No matter your area…
On July 1, the Rheumatology Research Foundation awarded grants to a wide range of rheumatology trainees and professionals. The recipients will receive funding for essential education and training, as well as innovative research projects. Their applications were closely examined by experts in different areas of the field to ensure awards went to the most promising…
A 67-year-old man with a recent onset of diffuse muscular pain and stiffness and an erythrocyte sedimentation rate of 55 is referred to you by his family practitioner. He has a history of non-insulin-dependent diabetes mellitus, but no history of headaches or swollen joints. He has chronic back pain, has had two surgeries and was…
Every single morning—even on weekends—Robert W. Simms, MD, wakes up at 3:45 and is out the door by 4:30 to swim, run or cycle for at least one hour. After weekday workouts, he then heads to his job at Boston University (BU) School of Medicine, where he serves as professor of medicine and rheumatology section…
CHICAGO—Amid what she called a “dizzying array of choices” for rheumatoid arthritis (RA)—from anti-TNF and anti-IL6-receptor therapies to B cell depletion to new biosimilar options—disease treatment should still revolve around several basic concepts, an expert said at the ACR State-of-the-Art Clinical Symposium in April. Joan Bathon, MD, chief of rheumatology at Columbia University in New…