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Displaying records 1 to 20 out of 2527 results for "documentation".
( Page 1 of 127 )
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Documentation Documentation
  Documentation standards
JANUARY 1, 2015
  Q&A: Documentation for body mass index
  Skilled Services: How to document for proper reimbursement
OCTOBER 9, 2015
  Featured member resource: ADR appeal documentation checklist
NOVEMBER 16, 2018
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
To accurately interpret and code physician documentation, the HIM department should employ
JUNE 4, 2014
JUSTCODING
  Have a question? Need to find a document? Not sure where to look? Watch this site demo now!
JANUARY 19, 2017
Can the plan of care serve as a way to document medications?  
What documentation is necessary for a medication review? The regulation
 Documentation
Using a streamlined approach to EHR documentation may help reduce stress for resident, according
AUGUST 7, 2015
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
Medical staffs across the country are discovering their governance documents are inadequate for t
  A Comprehensive Error Rate Testing (CERT) study found insufficient documentation
JULY 22, 2015
JUSTCODING
Now in its second edition, documentation-improv
APRIL 9, 2014
JUSTCODING
Now in its second edition, documentation-improv
JUNE 4, 2014
JUSTCODING
Now in its second edition, documentation-improv
AUGUST 13, 2014
JUSTCODING
Become more proactive. You no longer can wait for face-to-face documentation to arrive within sev
Insufficient documentation is the leading cause of improper payments for claims involving referri
OCTOBER 28, 2015
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
Providers don’t often receive education on clinical documentation, which can be a challenge
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
Q: Can you code strictly from emergency department (ED) documentation? Can you code from tes
DECEMBER 16, 2015
JUSTCODING
ACDIS, the Association of Clinical Documentation Impro
APRIL 7, 2011
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 19, 2016
We all know that ICD-10 codes will require more complete documentation. We’ve been t
An outpatient clinical documentation improvement (CDI) program should be aligned with a fa
Proper documentation is critical when it comes to supporting medical necessity and providing qual
Is it true that the following documentation is an improper certification statement on our
The Association of Clinical Documentation Improvement Specialists (ACDIS), the premier healthcar
SEPTEMBER 10, 2012
There has been a fair amount of coverage on the documentation requirements needed to assign ICD-1
The focus for clinical documentation improvement (CDI) specialists has historically been on the i
FEBRUARY 21, 2017
by Kirsten Dize Make completing documentation in the home a requirement for all
Coding and documentation should tell a patient's complete story. With the greater specific
  Medical staffs are discovering their governance documents are inadequate for tod
SEPTEMBER 18, 2014
Insufficient documentation led to approximately 97% of improper payments for kyphoplasty a
JULY 23, 2014
JUSTCODING
At ACDIS, it’s no surprise when we hear about clinical documentation improvement efforts
Take a close look at the documentation guidelines that CMS suggests for the practice improvement
by Kirsten Dize Strong documentation is key in home health, and implementation o
The Association of Clinical Documentation Improvement Specialists (ACDIS) released a new position
NOVEMBER 5, 2014
The first Clinical Documentation Improvement Week is taking place from September
SEPTEMBER 21, 2011
ACDIS, the Association of Clinical Documentation Improvement Specialists, the leading national as
FEBRUARY 8, 2011
Q: Our physicians document a diagnoses of pneumonia but do not normally make a specific
APRIL 9, 2014
JUSTCODING
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 Association of Clinical Documentation Improvement Specialists (ACDIS) last week updated its
OCTOBER 13, 2015
By utilizing the information documented in the record, coders can report the BMI from a dietitian
The documentation surrounding your QAPI program should include:  
MAY 21, 2014
JUSTCODING
Q: Is the statement “please document in a progress note to capture the severity of i
Clinical documentation is often overlooked during residency, yet without proper training, new ph
SEPTEMBER 9, 2016
In recent years, hospitals have increasingly focused on creating clinical documentation improveme
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
JANUARY 1, 2018
New EP: Avoid RFIs by keeping documents and service manuals in library “If it was
DECEMBER 1, 2017
Documentation: Getting the details right Joint Commission eli
DECEMBER 6, 2016
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
HCPro, Inc., and ACDIS, the Association of Clinical Documentation Improvement Specialists, today
JUNE 15, 2011
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
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV)
OCTOBER 8, 2014
JUSTCODING
APRIL 23, 2014
JUSTCODING
Q: I am a coder in a hospital outpatient setting. Our physicians document drug use in s
JULY 22, 2015
JUSTCODING
Documentation will be important to support supply utilization and payment. Claims
Regardless of the clinical background of those responsible for reviewing documentation, it can be
It’s an age-old question: How do you get physicians to support documentation improvement ef
Documentation example for coders in
OCTOBER 29, 2014
JUSTCODING
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician document
  Q: Is it okay to code a diagnosis if the physician documents two diagnoses usin
SEPTEMBER 24, 2014
JUSTCODING
By James S. Kennedy, MD, CCS, CDIP The physician documented “encephalopathy&
MARCH 25, 2015
JUSTCODING
Documentation example in
MARCH 4, 2015
JUSTCODING
The Certified Clinical Documentation Specialist (CCDS) exam hit a pretty big milestone last weeke
If you feel pretty confident as an agency that your documentation can pass muster and the totalit
ACDIS, the Association of Clinical Documentation Improvement Specialists
AUGUST 1, 2012
The St. Louis County Health Department recently discovered that a document containing PHI was ema
MARCH 11, 2015
JUSTCODING
JULY 22, 2015
JUSTCODING
"[A]s we enter into clinical practice, physicians face the burdens of documentation and reg
SEPTEMBER 17, 2015
SEPTEMBER 30, 2015
JUSTCODING
In the early days of clinical documentation improvement programs many staff members reported up t
Q: Can you tell me whether there is a resource that lists documents and required retentio
The patient care plan (485) is not a stand-alone documentation system; it is the legal record of
Residency training typically serves as physicians’ first exposure to the clinical document
AUGUST 11, 2017
Documenting medical necessity has become a big topic over the last several years and there has be
MARCH 22, 2019
Finding effective ways to continuously remind physicians of documentation improvement methods can
Finding effective ways to continuously remind physicians of documentation improvement methods can
Focus on documentation. CMS believes it is the responsibility of the homecare provider to attempt
NOVEMBER 20, 2013
JUSTCODING
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
SEPTEMBER 3, 2014
JUSTCODING
SEPTEMBER 23, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s pre
FEBRUARY 16, 2015
Coders are tasked with telling a patient’s story based on the documentation in the m
MAY 20, 2015
JUSTCODING
Q: I am looking for documentation or physician education tips related to ventilator manage
by: Kirsten Dize CMS’ revised OASIS Q&A document offers welcome insight
The Association of Clinical Documentation Improvement Specialists (ACDIS) honored the nation&rsqu
MAY 25, 2016
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
FEBRUARY 9, 2015
APRIL 9, 2014
JUSTCODING
A patient presents to the ED with a headache, nausea, and vomiting. The physician documented that
FEBRUARY 25, 2015
JUSTCODING
OCTOBER 8, 2014
JUSTCODING
Although documentation matters more and more in today’s world of ever-changing regulations,
AUGUST 4, 2017
Q: Is it okay to code a diagnosis if the physician documents two diagnoses using
ACDIS is proud to celebrate the 3,000th Certified Clinical Documentation Specialist (CCDS) creden
Q: When physicians continue to only document respiratory failure in the inpatien
JUNE 4, 2014
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 10, 2015
NOVEMBER 20, 2013
JUSTCODING
The Medicare Payment Advisory Commission's documents/Mar14Entire
MARCH 21, 2014
In the budget document released by the Office of Management and Budget, the White House's propose
Friday, April 11 is the deadline to apply for the Certified Clinical Documentation Specia
NOVEMBER 26, 2014
JUSTCODING
Physician documentation for the use of osteogenic stimulators for nonunion of fractures is often
JANUARY 28, 2015
JUSTCODING
Need another reason to avoid billing denials by ensuring proper documentation? A new study in the
AUGUST 26, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. What is th
OCTOBER 21, 2015
JUSTCODING
OCTOBER 14, 2015
JUSTCODING
Q: I have seen documentation of oliguric renal failure and non-oliguric renal failure. Wha
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
DECEMBER 30, 2015
ACDIS—the Association of Clinical Documentation Improvement Specialists—announced tod
MARCH 18, 2014
NOVEMBER 19, 2014
JUSTCODING
HCPro, Inc. and the Association of Clinical Documentation Improvem
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
New on JustCoding Platinum! New ICD-10-CM documentation examples in
JULY 9, 2014
JUSTCODING
Every provider has basic information he or she must document in the health record, says Lisa Ging
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
APRIL 8, 2015
JUSTCODING
Take an in-depth look at coding, documentation, and querying for acute kidney injury (AKI). Durin
MARCH 25, 2015
JUSTCODING
FEBRUARY 11, 2015
JUSTCODING
Incidents reports are a pain to fill out, but vital for documenting what happened and for pro
SEPTEMBER 3, 2015
In 2016, those sitting for the Certified Clinical Documentation Specialist (CCDS) exam face the b
Advancements in electronic health records (EHR) have improved nursing documentation and patient s
JANUARY 26, 2017
The proof of medical necessity strictly relies on the MD documentation and diagnosis and the skil
SEPTEMBER 23, 2015
JUSTCODING
MAY 6, 2015
JUSTCODING
OCTOBER 22, 2014
JUSTCODING
Q: The physician documented “encephalopathy” in the record of a patient who wa
Q: The primary physician documented subacute cerebral infarction and I am wondering whe
NOVEMBER 5, 2014
JUSTCODING
I’m always excited to read an article about clinical documentation improvement in the mains
A proposed CMS change to the 2017 Medicare Physician Fee Schedule will require surgeons document
SEPTEMBER 13, 2016
MARCH 19, 2014
JUSTCODING
ACDIS is preparing to draft its third incarnation of the popular The Physician Documentation I
APRIL 23, 2014
JUSTCODING
APRIL 30, 2014
JUSTCODING
MAY 7, 2014
JUSTCODING
JUNE 11, 2014
JUSTCODING
Knowing the bones of the feet, and ensuring they're being properly documented by providers
JULY 30, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
AUGUST 20, 2014
JUSTCODING
AUGUST 27, 2014
JUSTCODING
Documentation sample for coders in
NOVEMBER 12, 2014
JUSTCODING
Q: If a is patient admitted with malnutrition and the physician documented the patien
JANUARY 28, 2015
JUSTCODING
  Creating a new position to assume a physician’s documentation duties may l
APRIL 15, 2015
JUSTCODING
FEBRUARY 25, 2015
JUSTCODING
Click the PDF icon above to download. Included in this document:
MAY 13, 2015
JUSTCODING
JULY 15, 2015
JUSTCODING
While many case managers today work closely with clinical documentation improvement (CDI) special
JANUARY 5, 2016
On March 8, CMS posted a document in the Federal Register correcting technical and typog
The Association of Clinical Documentation Improvement Specialists (ACDIS) just launched a redesig
JUNE 20, 2016
The Association of Clinical Documentation Improvement Sp
OCTOBER 1, 2010
The Association of Clinical Documentation Improvement Specialists (
FEBRUARY 23, 2012
MAY 7, 2014
JUSTCODING
Q: We had a question regarding documentation in a record of SIRS due to acute peritonit
MAY 21, 2014
JUSTCODING
Q: When the surgeon documents excision of a complex pilonidal cyst with rhomboid flap c
JULY 8, 2015
JUSTCODING
NOVEMBER 11, 2015
JUSTCODING
Q: In the past few weeks, we noticed physicians are documenting acute conge
Q: If a physician documents sepsis due to decubitus ulcer and UTI due to indwelling catheter, c
Most coders and clinical documentation improvement (CDI) specialists are familiar with the Unifor
JANUARY 14, 2015
JUSTCODING
AUGUST 20, 2014
JUSTCODING
  When a provider fails to document whether a patient diagnosed with monoplegia ha
MAY 13, 2015
JUSTCODING
JUNE 18, 2014
JUSTCODING
JULY 29, 2015
JUSTCODING
The Association of Clinical Documentation Improvement Specialists (ACDIS), the nation’s onl
JANUARY 29, 2016
MARCH 26, 2014
JUSTCODING
MARCH 5, 2014
JUSTCODING
We want physicians to be very clear in their documentation about what’s wrong with the pati
MAY 13, 2015
JUSTCODING
CMS posted updated versions of all the guidance documents posted on the
MARCH 26, 2014
JUSTCODING
Q: The primary physician documented subacute cerebral infarction and I am wondering whethe
SEPTEMBER 17, 2014
JUSTCODING
Blogs from industry experts in healthcare that keep users up-to-date on the latest happenings in their fields.
Bylaws serve as the governing documents of the medical staff. Bylaws must meet the hospital&rsquo
DECEMBER 13, 2013
NOVEMBER 20, 2013
JUSTCODING
APRIL 9, 2014
JUSTCODING
APRIL 23, 2014
JUSTCODING
JUNE 4, 2014
JUSTCODING
MAY 28, 2014
JUSTCODING
JULY 9, 2014
JUSTCODING
JULY 16, 2014
JUSTCODING
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
If the hospital documentation, including history and physical and progress notes, doesn’t s
OCTOBER 22, 2014
JUSTCODING
What concerns you most about ICD-10 coding? Documentation shortcomings
JANUARY 21, 2015
JUSTCODING
What concerns you most about ICD-10 coding? Documentation shortcomings
JANUARY 28, 2015
JUSTCODING
MARCH 25, 2015
JUSTCODING
Those interested in taking the Certified Clinical Documentation Specialists (CCDS) credential exa
FEBRUARY 11, 2015
JUSTCODING
A January 2015 documents/reports/federal-trade-commissio
FEBRUARY 4, 2015
JUSTCODING
Coders and clinical documentation improvement specialists need a clear understanding of how to us
OCTOBER 7, 2015
Is your CDI program's query process a documented part of your policies and procedures? Does your
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
The Association of Clinical Documentation Improvement Specialists (ACDIS) will soon be launching
The National Resident Matching Program recently published its set of reports documenting how appl
OCTOBER 7, 2016
Generally, for Medicaid Advantage, the documentation is that the face-to-face date needs to be on
APRIL 2, 2014
JUSTCODING
AUGUST 6, 2014
JUSTCODING
NOVEMBER 19, 2014
JUSTCODING
Documentation Two strategies for holding physicians accountable
FEBRUARY 25, 2015
JUSTCODING
Although the rules for selecting QAPI data are flexible, CMS does require that programs document