As facilities vie for government incentives to implement electronic health record systems they may find CDI programs provide a hidden benefit.
The biggest challenge related to meeting governmental standards for “meaningful use” of EHR “is that they require physician documentation and...Read More »
Confusing coding guidelines and insufficient documentation have made neoplasms a target area as HealthDataInsights—the RAC for Region D—recently said it will take a closer look at MS-DRGs 837–948.
“…[T]here are opportunities for error within this subset of MS-DRGs,” says Paul Evans,...Read More »
CMS requires that orders for healthcare services be authenticated using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication and previous language in the CMS Program Integrity Manual required a “legible...Read More »
Q: If a CDI specialist or coder queries a physician and the response is written on the query letter is it legal to code from this? Or should the physician only respond in his or her progress note or discharge summary? Also, can the facility...Read More »
