Posted and filed under Coding, Compliance.

Clinical Documentation vs. Patient Care

The keystone of Clinical Documentation Improvement is that quality documentation often results in quality continuum of care, and while this is true, many physicians report that paying too much attention to documentation actually leads to poor patient care. This poses a dilemma for some providers; do they care for the chart or for the patient…

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Posted and filed under YouBeTheCoder.

You Be The Coder: Halloween Edition

Assess your knowledge of Evaluation and Management while taking our free E/M Calculator for a test drive! Review the below patient notes and plug the appropriate information into our audit tool. History of Present Illness (HPI) A 12 year old female patient is experiencing auditory hallucinations, severe head pain, and is presenting with abnormal posture. …

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Posted and filed under Coding, Medical Record Auditing, Payers.

Mammography Coding

In honor of Breast Cancer Awareness Month, we’ve decided to release a brief reminder to not only schedule a routine mammogram, but to recall the 2017 Mammogram Coding Changes. Mammography Coding The Centers for Medicare and Medicaid Services (CMS) announced in November 2016’s final rule that they would not be able to accommodate the new…

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