Healthcare organizations concerned about how to record data on patients’ social determinants of health are allowed to use non-physician documentation to support ICD-10 coding for common socioeconomic issues, says the…
Clinical documentation improvement (CDI) helps healthcare organizations capture meaningful data for improved quality reporting and clinician productivity. In an effort to ensure that the entire patient record is documented properly,…
Abstract Background A specific Electronic Health Record (EHR) for ophthalmology was introduced in an academic center in Germany. As diagnoses coding corresponding to the International Classification of Diseases Version 10…
One of the more notable things about the Centers for Medicare & Medicaid Services' revisions to its ICD-10 policy on Monday is the fact that the suggestions come straight from…