Richard Pinson, MD, FACP, CCS, is a principal and co-founder of Pinson and Tang, LLC. Dr. Pinson will be presenting on Day 2 of the 2018 ACDIS Symposium: Outpatient CDI. The title of his presentation is “Diabetic complications...Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
In many instances, the documentation for a particular service needs to be provided before the encounter. This is especially true for diagnostic tests such as MRI scans.Read More »
Many organizations have HCC tools built into their CDI software or EHRs that can help them capture HCCs. When providers click on a diagnosis or a condition, the tool will mark whether the diagnosis is an HCC. Other technology can extract pharmacy data, lab data, other diagnoses, and the problem...Read More »
By Anny Yuen, RHIA, CCS, CCDS, CDIP, and Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO
The terms “inpatient” and “outpatient” can refer to the clinical setting, but they also indicate the types of procedures performed. Inpatient procedures require that the patient be admitted to the...Read More »
A common theme that plays a critical role in portraying the patient encounter accurately in both the inpatient and outpatient environments is complete and precise documentation. General principles of medical record documentation...Read More »
Vinita Magoon, DO, JD, MBA, MPH, CMQ, presented a poster at the 2018 ACDIS Conference entitled “Using denial data to improve outpatient clinical documentation.” Read More »
Q:Under what circumstances would it be appropriate for a patient who does not meet inpatient criteria to be registered as outpatient receiving observation services?Read More »
