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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
In 2006 the Tax Relief and Health Care Act (TRHCA) included a provision for a 1.5% incentive payment to eligible providers who successfully submitted quality data to CMS. This provision included a cap on payments. The 2007 Medicare, Medicaid, and SCHIP Extension Act extended the program through 2008 and 2009. It also removed the TRHCA payment cap.
By consolidating this information into the Superbill, healthcare providers create a structured summary that facilitates claim submission and ensures proper documentation for payor review. This step is vital in maintaining accuracy and minimizing errors during the medical billing process. Step 5: Preparing and Submitting Claims [4]
Good documentation practice (recommended to abbreviate as GDocP to distinguish from "good distribution practice" also abbreviated GDP) is a term in the pharmaceutical and medical device industries to describe standards by which documents are created and maintained.
These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools.
Note: Most subscribers have some, but not all, of the puzzles that correspond to the following set of solutions for their local newspaper. CROSSWORDS
Point of care (POC) documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients. [10] The increased adoption of electronic health records (EHR) in healthcare institutions and practices creates the need for electronic POC documentation through the use of various medical devices. [11]