Tag: Clinical Documentation
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17 September 2018 - 13:46, by , in Blog, Post Acute, Comments off
A common question asked among coders is, “is this a complication or is this a sequela”?  Following specific coding guidelines will ensure that costly errors are avoided for these two very different coding situations. 
27 July 2018 - 14:55, by , in Blog, Compliance, Comments off
The July release of the Home Health OASIS July 2018 Quarterly Q&As brings promise that CMS is back on track to continue quarterly updates that address agency OASIS questions. Perhaps, one of the most complex responses was the insight provided on “what is” and “what is not” a surgical wound in the context of PleurX catheters.
13 June 2018 - 10:35, by , in Blog, Compliance, Comments off
With the Centers for Medicare & Medicaid Services (CMS) release of the updated Conditions of Participation (CoPs) in the beginning of 2018, it is more important now than ever for agencies to assess their compliance plan.  The new CoPs introduced the Infection Control Program, QAPI Program, Emergency Preparedness, and modifications to current CoPs. Surveyors will look to see if agencies have successfully introduced these new changes into their plans, as well as policies and procedures – paying special attention to the standards that relate to the highest quality patient care.
29 May 2018 - 11:32, by , in Blog, Compliance, Comments off
From from intake and registration to claim adjudication, there are several administrative and clinical functions that contribute to the timely capture and collection of patient service revenue. It is crucial for providers to identify compliance risk areas to realize revenue.
10 February 2018 - 9:14, by , in Blog, Compliance, Comments off
The Recovery Audit Contractor (RAC) Performant Recovery, Inc. announced last month that they will conduct a complex home health review for documentation and medical necessity. They will do an annual additional development request (ADR) limit that will be one-half percent (0.5%) of the total Medicare paid claims from the previous year.
15 December 2017 - 10:18, by , in Blog, Compliance, Comments off
Check out these tips when coding blindness and low vision. Documentation training and education is crucial to correctly code blindness and low vision conditions. Category-level tabular instruction at H54.- (Blindness and low vision) requires...
30 August 2017 - 18:27, by , in Blog, Compliance, Comments off
McBee’s Chief Nursing Officer, Jeri Ann Kelly, identifies the top three clinical documentation challenges and how to address them...