Tag Archives: documentation

Quality versus quantity…a real dilemma

Happy New Year to all! As we make (and break) many New Year’s resolutions this month, I’d like to talk about resolutions for quality.

I appreciate the challenges and pressures to get claims coded and out the door and meet productivity standards. I am sure many organizations think I live in an ivory tower and not in the real world. Let me just tell you that we all have some sort of productivity standards in our jobs for which we are held accountable (myself included). Finding the right balance means hitting the mark on productivity while still doing a quality job. Continue reading

Documenting medical necessity

CMS recently released a new National Coverage Determination (NCD), which was implemented on January 4. NCD 210.14 titled “Lung Cancer Screening with Low Dose Computed Tomography” is good news and expands the preventive services CMS offers its beneficiaries. Continue reading

Copy-paste in the EHR

Should physicians use the “copy-paste” function to document in the EHR?  In his latest blog post, 3M HIS blogger Jeremy Zasowski uses a whiteboard to sketch out the pros and cons, and offers two case studies that get to the heart of the copy-paste issue.

Watch the video here.

Copy-paste in the EHR title screen

 

Continue reading

They just don’t get it: Who is to blame for increased complication rates?

Let me start by saying Happy Holidays to everyone. However, I am feeling a bit like Mr. Scrooge. I have heard from many clients lately regarding their struggles with obtaining accurate complications rates. In almost every instance, there is finger-pointing (with coding and CDI taking the hit) and even software gets blamed for the increased capture of complications rates.

So let me explain a few things: Continue reading

Coast to coast with ICD-10

We’re now almost two months into ICD-10. I’ve been, literally, coast to coast during that time and have asked everyone how their transition is going. To my surprise, regardless of where physician practices were in their preparation when ICD-10 was delayed last year, everyone that I’ve visited with was well prepared for this year’s Oct. 1 implementation.

Many practices used the extra time to work on dual coding, testing of clearinghouses, reviewing new LCD policies, etc. Some groups were glad the implementation date was pushed back, but equally as many were not, having to retrain coders and providers on the new code set. As mentioned last month, there have been a few bumps, but the only consistent comment I hear is about coder productivity and documentation. Continue reading

What you don’t know might hurt you…the potential negative impact of CDI programs on quality outcomes data

We’ve all heard the phrase…”what you don’t know won’t hurt you.” That might be true in some settings, but in the world of documentation improvement this is definitely not the case.

Let’s look at a few commonly queried diagnoses and their impact on quality profiles. The first one is acute blood loss anemia (ABLA). Certainly this can be a diagnosis present on admission (POA), but many times it is a diagnosis clarified in the postoperative setting. And heaven forbid the provider document dilutional anemia even though it might actually be the case! On the plus side, this may increase reimbursement or impact severity of illness. On the negative side, ABLA not present on admission is a potentially preventable complication (PPC). Continue reading

HIMagine That! Collaborating on ICD-10 Documentation

Donna and Sue are joined this month by fellow 3M HIS blogger Jill Devrick.

Donna: Hi Sue. How was the AHIMA-AHDI summit? Didn’t you give a presentation?

Sue: The summit was really good, and yes, Jill Devrick and I gave a presentation on how CDI professionals and Healthcare Documentation Specialists can work together to improve the content of the medical record in light of the transition to ICD-10.

Donna: So tell me more…

Sue: You know what, let’s get Jill on the line and we can both tell you about it… Continue reading

Attention Physicians and Coders: CMS’ Advanced Analytics Paying Off – Big Time

My mother taught me that it’s impolite to say “I told you so.” My daughter tells me I’m bossy and health care compliance is pretty dry (she’s trying not to be impolite and say “boring”) but when millions of dollars are connected, it’s much more interesting and news worthy.

So, sorry Mom, but I told you so and I’ve been telling you since I began blogging. And yes, big brother and his whole family are watching. Continue reading

Twenty Years of Transcription

Twenty years ago, I began my journey in healthcare documentation technology. I’ve been traveling up and down memory lane for the past few days, thinking about how the healthcare industry has changed, and healthcare documentation tools and processes along with it.

Back in the mid-90s, healthcare documentation was almost entirely created for paper, whether it be handwritten notes and forms or transcribed documentation. Many of the hospital medical transcription departments I visited at that time were transitioning from typewriters and fancier word processing units to networked workstations running our DOS-based ChartScript application. I remember transcriptionists being concerned because a computer-based transcription system could measure productivity more consistently and precisely than the manual methods employed with typewriters and word processors. Continue reading

Physicians and Coders: No More Unspecified Care

The team I work with has done an enormous amount of work translating medical necessity policies from ICD-9 to ICD-10. And we have had many discussions regarding the codes that represent “unspecified” care in ICD-10. Should they stay in the translations – or go? Is ICD-10 specific enough to cover all care and coding contingencies now?

Unspecified Defined

An internet search (don’t you love being able to search so easily?) revealed:

Un-spec-i-fied: (adjective) meaning “not stated clearly or exactly”. Synonyms: unnamed, unstated, unidentified, undesignated, undefined, unfixed, undecided, undetermined, uncertain… Continue reading