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Displaying records 1 to 20 out of 4458 results for "clinical documentation".
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SORT RESULTS BY: RELEVANCY | PUBLICATION DATE
JustCoding’s Clinical Conditions Encyclopedia is the perfect reso
OCTOBER 1, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, clinical-documentation-improv
AUGUST 13, 2014
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
Incomplete documentation in patient clinical records can cause your organization legal and settle
SEPTEMBER 18, 2019
Providers don’t often receive education on clinical documentation, which can be a challenge
Increasing accountability in medicine has brought more attention to the importance of clinical do
SEPTEMBER 23, 2016
Residents are a little-utilized but critical link in the documentation chain that drives hospital
JULY 7, 2017
With the transition to ICD-10, some documentation issues have required the capture of new inform
With the transition to ICD-10, some documentation issues have required the capture of new informa
Residents are a little-utilized but critical link in the documentation chain that drives
JULY 14, 2017
The new AHA Coding Clinic for ICD-10-CM and ICD-10-PCS cleared up some confusion regarding
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
 Documentation
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
Q: What are some tips when evaluating our documentation system?
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
Clinical documentation improvement (CDI) programs need to expand their focus beyond CC/MCC capt
DECEMBER 2, 2015
JUSTCODING
AA best practice should identify clinical actions—assessment, teaching, procedures, coordin
Best practice should identify clinical actions—assessment, teaching, procedures, coordinati
Proper documentation is critical when it comes to supporting medical necessity and providing qual
NOVEMBER 20, 2013
JUSTCODING
 Although documentation matters more and more in today?s world of ever-changing regulations, med
AUGUST 4, 2017
Q: I’m in a little debate: Does documentation of the patient’s body mass in
MAY 7, 2014
JUSTCODING
  Why are physician queries so critical to accurate documentation and coding? The an
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
Physicians who provide E/M services must document the necessary clinical information to support t
by Kirsten Dize Strong documentation is key in home health, and implementation o
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
To date, Clinical Learning Environment Review (CLER) visits are scheduled to occur every 18 to 2
OCTOBER 27, 2017
Medicare allows electronic signatures as “alternative signatures” on clinical records
The American Health Information Management Association (AHIMA) and the Association of Clinical Do
MARCH 11, 2015
JUSTCODING
Q: If the physician documents “concerning for,” “considering,” “
AUGUST 12, 2015
JUSTCODING
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
By utilizing the information documented in the record, coders can report the BMI from a dietitian
Q: Can you code strictly from emergency room (ER) documentation? Can you code from test re
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
In the early days of clinical documentation improvement programs many staff members reported up t
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
Documentation Documentation
ICD-10-CM simplifies coding for sepsis provided the physician completely and accurately documents
NOVEMBER 18, 2015
JUSTCODING
Last Tuesday, NAHC submitted official comments to CMS on a pair of proposed clinical templates (o
Clinical documentation improvement (CDI) specialists and case managers share a common goal but of
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
No. The regulations do not mandate any particular form or format for documentation or confirmati
Q: Can you clarify the expectations related to documenting the discussion betwee
FEBRUARY 11, 2015
JUSTCODING
  CMS continues expand its ICD-10 Clinical Concepts Series for specialties on
AUGUST 26, 2015
JUSTCODING
Coders and clinical documentation improvement specialists need a clear understanding of how to us
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
Q: Is the statement “please document in a progress note to capture the severity of i
Clinical documentation improvement (CDI) programs need to expand their focus beyond CC/MCC captur
We all know that ICD-10 codes will require more complete documentation. We’ve been t
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
  Coders and clinical documentation improvement (CDI) specialists may not always a
JUNE 17, 2015
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
MARCH 19, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
MAY 27, 2015
JUSTCODING
JUNE 24, 2015
JUSTCODING
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
NOVEMBER 20, 2013
JUSTCODING
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
AUGUST 12, 2015
JUSTCODING
AUGUST 26, 2015
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
It’s an age-old question: How do you get physicians to support documentation improvement ef
by Kirsten Dize Make completing documentation in the home a requirement for all
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) s
NOVEMBER 18, 2015
JUSTCODING
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
  Documentation standards
JANUARY 1, 2015
HCPro, Inc. and the Association of Clinical Documentation Improvem
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
CMS recently updated its Clinical Laboratory Amendments (CLIA) for lab work at critical access ho
APRIL 12, 2016
Q: In the past few weeks, we noticed physicians are documenting acute conge
Last month, we laid the foundation to promote successful engagement of the coding and clinical
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
APRIL 23, 2014
JUSTCODING
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
MAY 6, 2015
JUSTCODING
JULY 29, 2015
JUSTCODING
APRIL 23, 2014
JUSTCODING
Regardless of the clinical background of those responsible for reviewing documentation, it can be
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
by Josh Poltilove Restructure clinical managers’ positions so they function
Q: Over the years I have heard differing opinions regarding whether clinical or coding exp
AUGUST 27, 2014
JUSTCODING
  Creating a new position to assume a physician’s documentation duties may l
JULY 15, 2015
JUSTCODING
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
Correct, complete documentation is the foundation of a sound medical record and compliant reimbur
JUNE 15, 2018
Announced in 2012, the ACGME’s Clinical Learning Environment Review (CLER) was established
JULY 21, 2017
  Documentation terminology that will not support the Medicare claim
A patient comes into the ED following an automobile accident. The physician documents that the pa
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
SEPTEMBER 3, 2014
JUSTCODING
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 23, 2014
JUSTCODING
Does your hospital have a clinical documentation improvement (CDI) program (i.e., a department, s
APRIL 30, 2014
JUSTCODING
MAY 14, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
APRIL 9, 2014
JUSTCODING
JUNE 4, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 9, 2014
JUSTCODING
In which format would you be most likely to access a clinical conditions library, which includes
JULY 16, 2014
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
APRIL 9, 2014
JUSTCODING
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
By Christopher Cheney Vision-impaired hospital patients have worse clinical outcom
MAY 8, 2019
You’ve probably heard that you need to beef up your clinical knowledge for ICD-10-CM
OCTOBER 8, 2014
JUSTCODING
Jeff comes in to the Fix ‘Em Up Clinic complaining of shortness of breath, a persistent cou
Agencies should consider implementing a Utilization Review (UR) model or a clinical manager as a
Q: Our facility is developing clinical definitions regarding types of atrial fibrilla
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
  A tool for your CNAs to help with accurate ADL documentation
  CMS issues guidance for handling insufficient documentation, ADRs
  Key documentation criteria for supporting the Medicare claim
SEPTEMBER 21, 2018
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
Blogs from industry experts in healthcare that keep users up-to-date on the latest happenings in their fields.
Managers should not assume that they can review every guideline, every item in Coding Clinic,
MAY 7, 2014
JUSTCODING
Q: If the clinical impression is physical assault, vomiting, blunt injury to abdomen, a
JUNE 11, 2014
JUSTCODING
  Optimizing Managed Care Partnerships to Maximize Clinical Outcomes
MARCH 16, 2018
I’m always excited to read an article about clinical documentation improvement in the mains
APRIL 2, 2014
JUSTCODING
by Tami Swartz Thoroughly examine clinicians’ documentation &mdash
Bylaws serve as the governing documents of the medical staff. Bylaws must meet the hospital&rsquo
DECEMBER 13, 2013
As we update our Clinical Privilege White Paper library, I’m often amazed at how mu
JULY 23, 2014
JUSTCODING
JULY 30, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 3, 2014
JUSTCODING
Does your facility perform outpatient clinical documentation improvement (CDI) reviews?
SEPTEMBER 10, 2014
JUSTCODING
SEPTEMBER 24, 2014
JUSTCODING
  A clinical learning environment review (CLER) visit to your facility is imminent
SEPTEMBER 12, 2014
Those interested in taking the Certified Clinical Documentation Specialists (CCDS) credential exa
Does your hospital have an inpatient or outpatient clinical documentation improvement (CDI) progr
DECEMBER 2, 2015
JUSTCODING
ACDIS is making several changes to the Certified Clinical Documentation Specialist exam effective
As of last week, 2,910 people hold the Certified Clinical Documentation Specialist credentia
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
Effective July 1, 2016, ACDIS will institute a policy and penalty fee for late Certified Clinic
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
AUGUST 26, 2020
Where does your organization stand with its clinical communications strategy? It is time to find
AUGUST 23, 2018
Written by Renee Kinder, MS, CCC-SLP, RAC-CT, Director of Clinical Education at Encore Rehabi
Hazards posed by batteries and alcohol preps prompt a review of fire safety issues in clinics
Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his to
Documentation of terminal illness at admission and during the hospice service period must be deta
Documentation of terminal illness at admission and during the hospice service period must be det
Jeff, an 18-year-old male, came into the Fix ‘Em Up Clinic with complete left oculom
Compliance MSPs, physicians, and hospital-owned clinics:
ACGME-accredited programs are required to establish clinical competency committees (CCC) to evalu
JULY 12, 2018
JUNE 10, 2015
JUSTCODING
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
CMS issues 2014 annual update for Clinical Laboratory Fee Schedule and Laboratory Servi
The popularity and growth of retail medical clinics and pharmacies continue to increase. And now
JUNE 18, 2015
  CMS is rolling out the next version of Transforming Clinical Practice Initiative Support and
Can the plan of care serve as a way to document medications?  
The following changes to the Certified Clinical Documentation Specialist (CCDS) credential
By Julie Mills, RN, MBA, senior manager, clinical solutions executive, PerfectServe
JANUARY 28, 2020
ACGME-accredited programs are required to establish clinical competency committees (CCC) to eval
JULY 12, 2018
In addition to documentation by physicians, nurses’ documentation affects patient safety,
JANUARY 8, 2020
DECEMBER 3, 2014
JUSTCODING
The use of modifiers -59 (distinct procedural service) and -91 (repeat clinical diagnostic labora
OCTOBER 14, 2015
JUSTCODING
What documentation is necessary for a medication review? The regulation
The National Practitioner Data Bank (NPDB) Final Regulations define clinical privileges as &ldqu
How many case managers and visit nurses do you recommend per clinical manager?
SEPTEMBER 24, 2014
JUSTCODING
DECEMBER 3, 2014
JUSTCODING
Effective documentation of the condition and the patients’ co-morbidities may help lawyers
In December 2014, CMS posted a document on its Advisory Panel on Hospital Outpatient Payme
As retail clinics expand in number and in scope of services, they could emerge as a threat to som
MARCH 26, 2014
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
FEBRUARY 25, 2015
JUSTCODING
HCPro is seeking feedback on your rural health clinic billing and compliance training needs. Plea
Medical staffs across the country are discovering their governance documents are inadequate for t
The Association of Clinical Documentation Improvement Speci
The Advanced CDI Boot Camp is designed for established clinical documentation depar
Q: Should I query for chronic respiratory failure if the documentation indicates the patient
JUNE 17, 2015
JUSTCODING
Coding Clinic's Fourth Quarter 2013 issue focuses considerable attention on ICD-10-
Following a Clinical Learning Environment Review (CLER) site visit, a report will arrive in your
MARCH 23, 2018
The number of retail health clinics in the U.S. continues to increase at a rapid clip along with
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev
By Cheryl Ericson, MS, RN, CCDS, CDIP Many clinical documentation improvement (CDI
JULY 29, 2015
JUSTCODING
AHA’s Coding Clinic is ramping up its focus on ICD-10 and we’ll help
JUNE 18, 2014
JUSTCODING
Recently my local clinic announced it had joined the “family” of practices owned by
As retail clinics expand in number and in scope of services, they could emerge as a threat to som
Agencies need to begin now to ensure that they are getting valid face-to-face documentation with the
AUGUST 12, 2015
JUSTCODING
Editor’s note: This is the second of a series of stories that will help medical clinics
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission crea
SEPTEMBER 23, 2015
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commission crea
SEPTEMBER 8, 2015
Medicare Boot Camp®—Rural Health Clinic Version is a one-day intensive course on Medica
By: Christopher Cheney, Senior Clinical Care Editor at HealthLeaders During the
by Pedram Mizani, MD, MHSA, family physician and chief clinical officer of the AmeriClerkship
FEBRUARY 2, 2018
In a recent frequently asked questions (FAQ) document released by the Centers for Medicare &
Q&A: Managing LS, EC, and EM documentation Editor
DECEMBER 20, 2016
A regulatory loophole in Florida state law allows cash-only medical clinics to skirt the licensi
MARCH 27, 2014
First-person accounts of clinical experiences help Massachusetts General Hospital (MGH) nurses re
MARCH 27, 2015
ACGME-accredited programs are required to establish a clinical competency committee (CCC) to eval
JUNE 5, 2015
ACGME-accredited programs are required to establish a clinical competency committee (CCC) to eval
JULY 10, 2015
The ACGME recently finished its second round of clinical learning environment reviews and has rel
AUGUST 31, 2018
Correct, complete documentation is the foundation of a sound medical record and compliant reimbu
JUNE 15, 2018
In the rush to complete ICD-10 coding education, documentation improvement, and system updates, H
OCTOBER 21, 2015
JUSTCODING
Announced in 2012, the ACGME’s Clinical Learning Environment Review (CLER) was established
JULY 21, 2017
FEBRUARY 11, 2015
JUSTCODING
What should our clinicians document if the patient hasn't had the flu vaccine yet? The pa
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, De
SEPTEMBER 27, 2018
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
APRIL 8, 2020
Is it true that the following documentation is an improper certification statement on our
Thank you for being a loyal subscriber to HCPro's Long-Term Care Clinical Pearls. T
A new health clinic in Savannah, Georgia opened its doors this week to free visits for gov
AUGUST 7, 2014
The problem of clinical alarm fatigue is so pervasive in hospitals that The Joint Commiss
SEPTEMBER 16, 2015
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
Provider-based clinics and departments are increasingly common at hospitals, but the rules for pr
This week the ACGME announced a four-year initiative to promote improvements in the clinical lear
NOVEMBER 6, 2015
Medicare Boot Camp—Rural Health Clinic Version is a one-day intensive course on Medicare co
Medicare Boot Camp—Rural Health Clinic Version is a one-day intensive course on Medicare co
by Deepak Gupta, MD, anesthesiology clinical assistant professor; and Sarwan Kumar, MD, inter
APRIL 28, 2017
DECEMBER 2, 2015
JUSTCODING
WRITTEN BY LENA BROWNING, MHA, BSN, RN, A CONSULTANT AT clinical.com
Consider adopting clinical pathways to increase nursing visit efficiency, decrease rehospitalizat
Measure a wound from inside edge to inside edge to correctly document wound size, and ensure that
We have been told that the following documentation would position us for a potential clai
The clinical nurse leader role, introduced more than a decade ago as way to improve patient outco
APRIL 24, 2015
Struggling to identify the clinical indicators needed to qualify a diagnosis as a complication/co
APRIL 22, 2015
JUSTCODING
CMS followed through with its proposal to restructure APCs for nine clinical families in the 20
A Virginia dermatology clinic
SEPTEMBER 6, 2016
What pitfalls can you avoid to ensure proper documentation? These are eight common mistakes made:
JANUARY 28, 2020
The Mayo School of Graduate Medical Education at Mayo Clinic in Jacksonville, Florida, is using a
APRIL 15, 2016
The documentation surrounding your QAPI program should include:  
MAY 21, 2014
JUSTCODING
By Megan Batty Ensure that medical record documenta-tion clearly documents a canc
By Christopher Cheney, HealthLeaders Media Cancer clinics are mak
APRIL 30, 2020
by Deepak Gupta, MD, anesthesiology clinical assistant professor, Wayne State University, Det
JUNE 24, 2020
The electronic document management system (EDMS) plays a role in designing the official legal h
Nurses new to home health struggle with the completion of documentation related to patient care.
CMS doesn't require Medicare Advantage plans to have a face-to-face document for home health. Bu
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
Local ACDIS chapters provide a vital networking and educational service to clinical documentation
On April 10, 2020, CMS issued a proposed ruledocuments/2
MARCH 5, 2014
JUSTCODING
Two new conditions in our clinical-conditions-encyclope
NOVEMBER 5, 2014
JUSTCODING
A patient has the right to access his or her clinical information, request a copy of his or her
The ACGME’s Clinical Learning Environment Review (CLER) program aims to provide feedback to
JANUARY 6, 2017