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Cutting Costly Codes Act of 2013 and ICD-10-CM

Below is the text taken from a government website.  Even though it was drafted in 2013 and is representative of efforts in Texas to seek a delay in ICD-10.  The text of the bill is provided here.  More current information on this topic is available from AHIMA at the following location. 113th CONGRESS 1st…

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Medical Necessity

Medical necessity should be considered foremost when determining the appropriate level of documentation of the history, physical examination and complexity of medical decision making, usually contained within the assessment and plan of an encounter note. If a patient presents with a fairly straightforward problem (e.g., tension headache) and after a…

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Prepare to Fight ICD-10-CM Denials

ICD-10-CM will be the mandatory code set for reporting starting on October 1, 2015, unless another unforeseen issue arises in the federal government that leads to its delay.   The complexity of ICD-10-CM as compared to ICD-9-CM have gone up markedly.  This will increase the likelihood of inaccurate coding at the healthcare provider institution level, coding…

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Beware of the Problem List in Compliance Audits

The problem list is a required feature of certified EHRs and must be used by providers in order to attest for Meaningful Use, starting with Stage 1.  Prior to Meaningful Use, problem lists were used inconsistently in the outpatient setting.  They have greatest value in primary care and are intended to…