The adage frequently cited in healthcare settings, “If it isn’t documented, it wasn’t done,” still rings true for the key components required in a patient’s medical record. The note in the medical record must sufficiently describe all of the services furnished to patients on a specific date. The essential requirements to appropriately bill a claim…
New methods of gene sequencing have resulted in improved identification of mutations in patients and increased availability of genetic testing in rare diseases. Despite these exciting advances, a majority of patients lack identifiable mutations and the underlying disease etiology remains an enigma. Somatic mosaicism (SM) may be an explanation for some of these clinically challenging…
The operations management team in healthcare practices is expected to have an effective coding compliance program in place that is continually evaluated and reevaluated. To accurately assess the program’s effectiveness, several outcome indicators must be measured, including error rates in the provider’s documentation and the electronic health record (EHR). Due to increased scrutiny by the…
The ICD-10 page on the Centers for Medicare & Medicaid Services (CMS) website features a countdown clock that shows the time left until Oct. 1, 2015, the date on which compliance with the new code set becomes mandatory. By the time this issue goes to press, the clock will read 90 or fewer days. Time…