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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 ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
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]
Progress Note - This template represents a patient's clinical status during a hospitalization, outpatient visit, treatment with a LTPAC provider, or other healthcare encounter. [ 14 ] Transfer Summary - The Transfer Summary standardizes critical information for exchange of information between providers of care when a patient moves between ...
Healthcare quality and safety require that the right information be available at the right time to support patient care and health system management decisions. Gaining consensus on essential data content and documentation standards is a necessary prerequisite for high-quality data in the interconnected healthcare system of the future.
(99201–99215) Office/other outpatient services (99217–99220) Hospital observation services (99221–99239) Hospital inpatient services (99241–99255) Consultations (99281–99288) Emergency department services (99291–99292) Critical care services (99304–99318) Nursing facility services
Modifier: the appropriate use of a modifier allows these code pair to be reported together. In most cases, the -59 modifier is used, although there are other acceptable modifiers. These modifiers must be supported by documentation in the medical record. No Modifiers: these code pairs should never be reported together, regardless of modifiers.
A clinical coder therefore requires a good knowledge of medical terminology, anatomy and physiology, a basic knowledge of clinical procedures and diseases and injuries and other conditions, medical illustrations, clinical documentation (such as medical or surgical reports and patient charts), legal and ethical aspects of health information ...
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