Men’s Health Week has been celebrated around Fathers Day. As we pay observance to men’s health, it is very important to keep in mind that, when we emphasize men’s health, we are also acknowledging women who help men to maintain their health – and help to bring it to the fore front.  Men’s health include body systems that are specifically for Males, especially the prostate. We must also keep in mind areas that are considered important to male health, but are a...
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Historically, hospitals and physicians have had considerable discretion over whether a patient is admitted to the hospital or is treated as an outpatient. CMS instructed physicians to generally admit patients expected to be in the hospital twenty-four hours or more but noted that a patient's admission would not be covered or not covered "solely on the basis of the length of time the patient actually spends in the hospital." CMS emphasizes the role played by physicians in making this determinat...
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Hope that all are having a reflective New Year! As we begin this new year, let’s just keep in mind our due diligence regarding E&M coding (and the documentation required to support the levels of services & codes selected). Regulatory agencies are giving physician practices 1 fiscal year of “grace” before enforcement of recoupments and denials for E&M claims.  Let’s remember to have discussions regularly with our practice managers, coders & bil...
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There is a lot going on in our world today. Let us keep others in our thoughts…… Otherwise, all continues to be quiet on the practice front.  We all are working diligently to continue to provide quality-of-care to our patients and balance the fine line of communicating that care to 3rd party reviewers explicitly & concisely. As 2015 comes to its wonderful, festive finale there are many (at times overwhelming) details to our practices of medicine that we must keep ...
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Well, everyone we've survived October 1, 2015 !!!
Some have equated October 1st, as being similar to Y2K - the non-occurrence...and I must admit the Earth did not get swallowed up and disappear from the universe. We are all still here. It has been a quiet transition, and I'm so happy for that. The stressors within healthcare were truly palpable - especially regarding physician documentation and coding.   Hooray for us. We survived.   We must continue to strive to become familiar with the new language of ICD-10 because i...
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Looking Forward to the Future... Which begins October 1, 2015
We are only about one month away from  implementation of ICD -10. Finally!!   Documentation specificity has been needed for many years throughout healthcare. ICD-9 outgrew the descriptive clinical terms that captures severity of illness and medical necessitymany years ago. We should be very happy that the specificity of ICD -10 allows healthcare providers to be able to rise above the generalizations of severity-of-illness, and to specifically capture the immediate...
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The Affordable Care Act (ACA) Pt.1 - Welcome to Population Medicine
With the constitutionality of the Affordable Care Act (ACA) recently being upheld by the Supreme Court we must now start working toward the goals of this future direction of healthcare. Namely population medicine and health. Let's begin to look at the potential directions of the future of healthcare that we must now embrace. The Affordable Care Act's premise is to increase the availability of health care coverage to make it more affordable, which it increases accessibility for all US citizens. ...
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Communicating Chronic Conditions
In this space we will discuss relevant, important documentation tips that will help all physicians capture their severity of illness and medical necessity in the inpatient and ambulatory settings. We don't have to wait for ICD-10 to begin to document more appropriately so that third-party payers and regulatory agencies understand the quality of care being provided to patients. Let's keep in mind that in 2014 over $4.5 billion was recouped from healthcare by regulatory agencies. They only expect ...
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Posted in: | Tags: medication , monitoring , therapy , currently stable , history of illness , ICD-10 , medical necessity , documentation | Comments (0) | View Count: (1004)
Health Care and Its Providers’ Clinical Documentation
Healthcare is going through such a change today but it's a good, and needed. As healthcare, in spite of what everyone says, is becoming slightly more segmented – because multiple individuals are take may be taking care of any one episode of patient care. It doesn't mean that the healthcare is deteriorating. In fact it can mean that there is significantly improved care being provided - as long as the clinical documentation communications between the providers is concise and explicit. Documentati...
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Clinical Documentation and Ebola
When it comes to explicitly documenting such universally feared diseases, such as Ebola, we have to put the exact signs and symptoms, and their degree at time of seeing the patient each and every assessment, explicitly. This will allow to determine improvement or deterioration of the patient. Significant communicable diseases such as Ebola just help bring this point to the forefront. We need to have this clarity and explicitness and documenting signs symptoms diagnoses medical decision-making an...
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