Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

Remote Workforce vs. Onsite Staff

Having a remote workforce has many benefits to the employer. Using a vendor to provide the remote staff has even more benefits. Read more about the pros and cons from a Sr. HIM Director’s perspective…

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Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

Specified vs. Unspecified Coding Documentation; What’s the Big Deal?

Clinical Documentation Improvement (CDI) ensures that the medical records doctors, nurses, and other healthcare professionals maintain are detailed, precise, and reflect the true nature of a patient's condition and the care provided. Read on to see why this matters...

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Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

Top Issues Found on Medical Coding Audits

Medical Coding Audits will ensure your organization is compliant with CMS and Payor Guidelines, improves your provider documentation practices, has a positive impact on your quality scores, and can significantly increase your revenues.

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Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

Choosing the Right Medical Coding Auditing Vendor

How do you choose the right medical coding auditing vendor? There are several crucial requirements a vendor must meet in order to bring optimal and meaningful support for your organization’s revenue cycle business line.

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Robyn Petersen, RHIT, CPC, CCS, CPMA Robyn Petersen, RHIT, CPC, CCS, CPMA

What is the 2 Midnight Rule?

You are in the hospital; are you an Inpatient or just on Observation? Why do you care? Because one is covered by insurance and the other may not be, which means YOU WILL BE PAYING!

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Diane Passmore, CDME Diane Passmore, CDME

PECOS Check

Are you up to par on the CMS requirements surrounding Provider, Enrollment, Chain and Ownership System (PECOS)? STAR Medical Auditing Services can help! Reach out to learn about our DMEPOS Expert who can keep you on track so you do not lose your Medicare billing privileges!

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Robyn Petersen, RHIT, CPC, CCS, CPMA Robyn Petersen, RHIT, CPC, CCS, CPMA

Considering Offshore Medical Coders? Read this…

Healthcare Organizations must consider all the pros and cons before choosing to use offshore coding staff. Here are a few issues and pain points to help you make the right choice.

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Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer

Remote Patient Monitoring is taking Telehealth to the Next Level

Remote Patient Monitoring is the practice of physicians and mid-level providers using technology devices to monitor a patient from the comfort and privacy of their own home or other location such as a SNF or Long Term Care facility.

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Tammy Arnold, RN, HCS-D, COS-C Tammy Arnold, RN, HCS-D, COS-C

Hospice Claims and Election Statements

Is your Hospice agency getting claim denials due to Election Statement omissions? The National Hospice and Palliative Care Organization (NHPCO), together with CGS, NGS, and Palmetto (three of the seven Medicare Administrative Contractors), have found a solution!

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Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

How Will You Determine Coding Productivity?

The healthcare industry is rapidly evolving, and efficient coding practices are crucial for both accuracy and compliance. The use of technology by implementing advanced coding software and systems can boost productivity by automating repetitive tasks and helping coders stay up-to-date with ever-changing healthcare codes and regulations. Additionally, providing ongoing training and professional development opportunities for your remote team can enhance their coding skills and efficiency.

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Larry LaBarge, RN, CPHQ, CMSRN Larry LaBarge, RN, CPHQ, CMSRN

Navigating the Distinction: Inpatient vs. Observation Level of Care Auditing

In the intricate realm of healthcare, understanding the nuances between inpatient and observation levels of care is crucial for accurate billing and optimal resource allocation. Auditing these levels of care ensures that patients receive the right treatment while healthcare providers adhere to regulatory guidelines.

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Marlisa Coloso, RHIA, CRCR, CCS Marlisa Coloso, RHIA, CRCR, CCS

Retaining Medical Records

Retaining medical records is a key function of Health Information Management. There are many nuances to ensure retention regulations are complied with. Regulations can vary from state to state.

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Robyn Petersen, RHIT, CPC, CCS, CPMA Robyn Petersen, RHIT, CPC, CCS, CPMA

Coding for Primary Cancer and Metastatic Cancers

When coding malignant neoplasms, there are several coding guidelines we must follow. To properly code a malignant neoplasm, the coder must first determine from the documentation if the neoplasm is a primary malignancy or a metastatic (secondary) malignancy stemming from a primary cancer.

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Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer

Respiratory Coding in FY2020

Often in emergency and acute care healthcare settings, we find patients with a diagnosis of “Respiratory Failure.” Clinical coding and clinical documentation improvement (CDI) professionals need to have a strong knowledge and understanding of both medical/clinical aspects of diseases as well as the coding guidelines and rules. This blog includes a brief discussion of the clinical aspects and ICD-10-CM coding of Respiratory Failure.

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Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer Gloryanne Bryant, RHIA,CDIP, CCS, CCDS, AHIMA ICD-10-CM/PCS Trainer

Sepsis Documentation and Coding Guidelines (2020 Update)

We know that SEPSIS is a life-threatening condition and there has been much discussed about this subject in many clinical circles as well as in clinical coding and clinical documentation improvement (CDI). The golden rule for the HIM Coding and CDI professional is that we must have the diagnostic documentation by the provider in order to assign the ICD-10-CM code(s) and follow Official Guidelines.

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Robyn Petersen, RHIT, CPC, CCS, CPMA Robyn Petersen, RHIT, CPC, CCS, CPMA

Tips for Documenting and Coding Injections and Infusions

Avoiding claims denials requires compliance with coding guidelines.  In CPT, a common area of noncompliance is the documentation and coding of injections and infusions.  The Emergency Room is one service area wherein injections and infusions are common treatments for a multitude of diagnoses.  

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