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…
Take the challenge. B—The presenting problem(s) is what is evaluated during the history and examination by the provider. The chief complaint is in the patient’s own words or is a follow-up for his or her current condition. The history of present illness, along with the review of systems, usually guides the provider through the examination….
Evaluation & Management Documentation Quiz What element drives an evaluation and management (E/M) visit? The chief complaint in the patient’s own words of why he or she is in the practice for that date of service. The presenting problem(s) being discussed with the physician for that patient during the visit. The examination performed on the…
You can now use the updated Centers for Medicare & Medicaid Services (CMS) MIPS Participation Lookup Tool to check on your 2018 eligibility for the Merit-Based Incentive Payment System (MIPS). Enter your National Provider Identifier (NPI) in the tool to find out whether you need to participate during the 2018 performance year. Changes to…
Technology in medicine is no longer new or trendy. It’s pervasive. Rheumatologists may now assume a patient has searched online for information about his or her diagnosis or potential therapies. Both physicians and rheumatology health professionals should acknowledge their patients’ Internet surfing and find out what they’ve read, says Betsy Roth-Wojcicki, RN, MS, CPNP, an…
Fifteen women and men seated around a conference table in a New York City hospital listen intently to one of their peers. A 40-year-old elementary school teacher shares her challenges related to the intersection of rheumatoid arthritis (RA) and the responsibilities of a demanding job.* With the support and counsel of fellow group members, the…
Through much of the 20th century, dedicated rheumatic disease units were found in hospitals across the U.S. and countries around the world. In the latter part of the century, this began to change, with hospitals moving toward the consult model of care for rheumatic patients. This change reflects larger shifts in the medical world toward…
Many rheumatology patients have complex conditions and require the added expertise of colleagues in other fields, such as pulmonology, neurology or dermatology. This is even more true when patients with complex care issues are referred to academic medical centers. At such centers, patients often travel hours for an appointment and see more than one provider….
RheumPAC is the ACR/ARHP’s nonpartisan political action committee (PAC) that works to elect and support pro-rheumatology candidates. It is the only PAC dedicated to the interests of the rheumatology profession. RheumPAC was created 10 years ago with the mission of electing and supporting federal lawmakers who understand and are in a position to support the…
The CMS has implemented a few changes to its 2018 MIPS submission categories. Not only will it be adding a cost category, but it has recently announced the renaming of the Advancing Care Information (ACI) category to Promoting Interoperability (PI) to focus on interoperability, improving flexibility and relieving administrative burdens. The CMS confirmed this will…