Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.

I understand how a medical professional can undervalue their services and down-code unintentionally. What I don’t understand is how, if a provider is selecting an appropriate level of service, they fail to fulfill the requirements to bill at that level. CPT provides us with a rubric, for Pete’s sake!

Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.

When I was in grade school, they assigned an essay, gave you a topic, and turned you loose. Kids today are given a rubric: a precise recipe detailing exactly what is needed to achieve the various grades. If you don’t do an introductory paragraph with three sentences, your grade is predictably adjusted downward. You know what your teacher’s expectations are.

Often, the determining factor ends up being the review of systems (ROS). With a compliant caveat, it can always be rendered complete. And any patient can have a constitutional assessment and examination of eyes, mucous membranes, lungs, heart, abdomen, and neurological and psychiatric systems to fulfill a comprehensive physical examination. Therefore, any patient can have a Level 5 history and physical examination documented. The rubber meets the road at MDM. What is the nature of the presenting problem? Is there medical necessity to perform a comprehensive history and physical?

Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks.  Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.

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The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.

Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.

I have been doing a project assessing emergency providers’ documentation and their evaluation and management (E&M) levels of service (LOS), and want to share some information with you.

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Well, this is the last RACmonitor news edition of the year, so it’s time for my annual Hirsch’s Heroes. As a reminder, last year my

In the ED, for initial hospital or observation care, and for other new patient care in non-office venues, the threshold must be met for all three components. Established patients, such as those receiving subsequent hospital, observation, or nursing facility care, must meet two out of the three components. I recommend that MDM is always one of the components.

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Anyone who deals with professional fees anywhere other than in the office is familiar with trying to get providers to comply with the CPT (Current Procedural Terminology®) component requirements. Those components are history (which comprises history of present illness, past medical, social, and family history, and review of systems), physical examination, and complexity of medical decision making (MDM). Office billing is no longer component-based, since January 2021.

Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.

62201. Within the plan area or for purposes of revitalization an authority may: (a) Purchase, lease, obtain option upon, acquire by gift, grant, bequest ...

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I instruct my providers and coders to assess the presenting problem and determine which bucket the patient belongs in, according to medical necessity: critically ill (or injured, for all categories; cross 30 minutes – critical care time, otherwise 99285), really sick (99285), sick (99284), somewhat sick (99283), not particularly sick (99282), or not sick and shouldn’t even be in the ED (99281). Then, I tell them to make sure their documentation supports whatever level they picked.

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Programming Note: Listen live to Dr. Erica Remer as she cohosts Talk Ten Tuesdays with Chuck Buck, Tuesdays at 10 Eastern.

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There are guidelines as to what constitutes problem-focused versus expanded problem-focused versus detailed versus comprehensive histories and physical examinations. I can’t understand not including at least four elements for the HPI – what is the issue, how bad is it, when did it start, is it constant or fluctuating, does anything make it worse or better, are there any associated symptoms? These are questions that can and should be asked and documented for any condition. Everyone should have some elements of PFSH – medications and allergies, past medical history, and whether a patient smokes, drinks, or does drugs – those elements are always clinically relevant.

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The difference between levels 2 and 3 is the complexity of MDM. The difference between levels 3 and 4 is the extent of the history and physical examination. I tell providers to figure out where on the spectrum the presenting problem lands and then flesh out the history and physical examination to satisfy the requirements for the appropriate LOS.

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Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

Dec 15, 2024 — Milwaukee WI ZIP Code 53201 Profile, Interactive Map, Demographics, Income, Economy, Housing and School Attendance Areas.