The widespread implementation of electronic medical records (EMRs) and electronic health records (EHRs) has significantly changed the quality and quantity of healthcare for both the better and the worse. The digitalization of medical records provides comprehensive documentation of all events and actions associated with an individual’s medical care. Likewise, legibility, accountability and credibility are greatly…
Take the challenge. Answers: B: No—Only the treating physician can take the HPI. The medical assistant is allowed to take the review of systems. If the documentation indicates the treating physician did not take the HPI, the insurance can deny the claim as not medically necessary. B: No—If the high-risk medication is not assessed and…
To be an effective practice owner, it is necessary to understand the financial circumstances and environment of the practice’s operation. Well-managed practices prevent the loss of time and money. Therefore, to improve productivity and operating efficiencies, you need to have a basic understanding of billing and payment initiatives that will impact the practice’s bottom line….
In its 2016 Work Plan, the HHS Office of Inspector General (OIG) outlined its plans for audits and evaluations of covered entities to work on creating a permanent and more structured audit program. In light of their focused effort, the Office for Civil Rights has indicated that they will concentrate on areas of high risk…
In an age of constant change and regulations, one thing remains the same in coding and billing: If it’s not documented, it wasn’t done. This is the main rule for documentation. Good documentation is and always has been the foundation of accurately capturing a provider’s work and the patient’s condition, management and treatment. Introduced by…
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…
Full implementation of ICD-10 will go live on Oct. 1, 2015, and congressional leaders have confirmed there will be no further delays. The transition to ICD-10 is not just a simple update; it is a major revamping of diagnosis coding. With the complexity of coding using the ICD-10 system and the high risk of disruptions…
Are your medical records up to date and complete? Medical records should always be complete and have accurate documentation to avoid violating the Health Insurance Portability and Accountability Act or other documentation guidelines.
Has your practice ever experienced the disappointment of being downcoded because of lack of supporting documentation?
Do you want to save your practice time and money? Here’s a tip: Stay on top of documenting your patients’ records.