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…
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...
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.
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.
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!
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!
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.
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.
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!
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.
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.
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.
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.
Don’t forget the 7th character when assigning Chapter 19 ICD-10-CM diagnosis codes!
The 7th character represents the type of encounter, or phase of treatment; this could be an initial encounter, a subsequent encounter, or a sequela (previously known as a late effect).
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.
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.
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.