Clinical Documentation Reference Guide First Edition

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Clinical Documentation Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 13 pages
File Size : 41,8 Mb
Release : 2020-03-12
Category : Medical
ISBN : 9781626889798

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Clinical Documentation Reference Guide - First Edition by AAPC Pdf

It's not the quantity of clinical documentation that matters—it's the quality. Is your clinical documentation improvement (CDI) program identifying your outliers? Does your documentation capture the level of ICD-10 coding specificity required to achieve optimal reimbursement? Are you clear on how to fix your coding and documentation shortfalls? Providing the most complete and accurate coding of diagnoses and site-specific procedures will vastly improve your practice’s bottom line. Get the help you need with the Clinical Documentation Reference Guide. This start-to-finish CDI primer covers medical necessity, joint/shared visits, incident-to billing, preventative care visits, the global surgical package, complications and comorbidities, and CDI for EMRs. Learn the all-important steps to ensure your records capture what your physicians perform during each encounter. Benefit from methods to effectively communicate CDI concerns and protocols to your providers. Leverage the practical and effective guidance in AAPC’s Clinical Documentation Reference Guide to triumph over your toughest documentation challenges. Prevent documentation deficiencies and keep your claims on track for optimal reimbursement: Understand the legal aspects of documentation Anticipate and avoid documentation trouble spots Keep compliance issues at bay Learn proactive measures to eliminate documentation problems Work the coding mantra—specificity, specificity, specificity Avoid common documentation errors identified by CERT and RACs Know the facts about EMR templates—and the pitfalls of auto-populate features Master documentation in the EMR with guidelines and tips Conquer CDI time-based coding for E/M The Clinical Documentation Reference Guide is approved for use during the CDEO® certification exam.

The Clinical Documentation Improvement Specialist's Handbook, Second Edition

Author : Heather Taillon
Publisher : HC Pro, Inc.
Page : 171 pages
File Size : 44,7 Mb
Release : 2011-01-21
Category : Medical
ISBN : 9781601467751

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The Clinical Documentation Improvement Specialist's Handbook, Second Edition by Heather Taillon Pdf

The Clinical Documentation Improvement Specialist's Handbook, Second Edition Marion Kruse, MBA, RN; Heather Taillon, RHIA, CCDS Get the guidance you need to make your CDI program the best there is... The Clinical Documentation Improvement Specialist's Handbook, Second Edition, is an all-inclusive reference to help readers implement a comprehensive clinical documentation improvement (CDI) program with in-depth information on all the essential responsibilities of the CDI specialist. This edition helps CDI professionals incorporate the latest industry guidance and professional best practices to enhance their programs. Co-authors Heather Taillon, RHIA, and Marion Kruse, MBA, RN, combine their CDI and coding expertise to explain the intricacies of CDI program development and outline the structure of a comprehensive, multi-disciplinary program. In this edition you will learn how to: Adhere to the latest government and regulatory initiatives as they relate to documentation integrity Prepare for successful ICD-10 transition by analyzing your CDI program Step up physician buy-in with the improved education techniques Incorporate the latest physician query guidance from the American Health Information Management Association (AHIMA) Table of Contents Chapter 1: Building the CDI Program Chapter 2: CDI and the healthcare system Chapter 3: Application of coding guidelines Chapter 4: Compliant physician queries Chapter 5: Providing physician education Chapter 6: Monitoring the CDI program What's new in the Second Edition? Analysis of new industry guidance, including: AHIMA's "Managing an Effective Query Process" and "Guidance for Clinical Documentation Improvement Programs." CMS guidance from new IPPS regulations, MLN Matters articles, Quality Improvement Organizations, and the Recovery Audit Contractor (RAC) program, among others Strategies to help you incorporate the guidance into your CDI program. Tools to help you interpret MAC initiatives and RAC focus areas to enhance your CDI program and help prevent audit takebacks New sample queries, forms, tools, and industry survey data BONUS TOOLS! This book also includes bonus online tools you can put to use immediately! Sample query forms Sample job descriptions for CDI managers, and CDI specialists Sample evaluation form for CDI staff Sample pocket guide of common documentation standards

Evaluation and Management Coding Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 14 pages
File Size : 49,9 Mb
Release : 2020-06-30
Category : Medical
ISBN : 9781626889835

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Evaluation and Management Coding Reference Guide - First Edition by AAPC Pdf

Defeat the challenges that threaten your E/M claims and compliance success. Evaluation and management (E/M) services are the lifeblood of your revenue stream, and yet they’re the most problematic to report. Claim denials remain high. E/M coding errors, in fact, rose from 11.9% in 2018 to account for 12.8% of CMS’s overall 2019 improper payment rate. How much E/M revenue are you losing? Safeguard your organization from claim denials and audit scrutiny with the Evaluation & Management Coding Reference Guide. Our experts break down E/M coding rules and requirements into simple, manageable steps written in everyday language to boost your E/M reporting skills. Learn how to capture the key components of medical history, physical exam, and medical decision-making—and capitalize on real-world clinical scenarios to prevent over- or under-coding. The Evaluation & Management Coding Reference Guide will help you prep for 2021 E/M guideline changes overhauling new and established office and outpatient services, and walk you through online digital E/M services, remote physiologic monitoring, and more. Master the ins and outs of E/M coding—CPT® guidelines, level of service, modifiers, regulations, and documentation guidelines. Put an end to avoidable denials and optimize your E/M claims for full and prompt reimbursement. Benefit from expert tutorials covering the spectrum of E/M reporting concepts and challenges: Prep for 2021 guideline changes and their impact on your organization Master the ins and outs of E/M guidelines in CPT® Capture the seven components of E/M services Sort out medical decision-making coding Avoid the pitfalls of time-based coding Nail down specifics for critical care E/M services Clear up modifier confusion Understand NPPs rules for same-day E/M services Take the guesswork out of complexity determinations Get the details on coding surgery and E/M together Learn the principles of E/M documentation

Coding for Medical Necessity Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 17 pages
File Size : 50,6 Mb
Release : 2020-03-18
Category : Medical
ISBN : 9781626889804

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Coding for Medical Necessity Reference Guide - First Edition by AAPC Pdf

Master coding concepts related to medical necessity and report compliant codes for your services. Revenue loss, rework, payback demands—how much are medical necessity errors costing your practice? And that’s to say nothing of potential civil penalties. Get medical necessity wrong and it’s considered a “knowingly false” act punishable under the FCA. Stay liability-free and get reimbursed for your services with reliable medical necessity know-how. AAPC’s Coding for Medical Necessity Reference Guide provides you with step-by-step tutorials to remedy the range of documentation and coding issues at the crux of medical necessity claim errors. Learn how to integrate best practices within your clinical processes—including spot-checks and self-audits to identify problems. Benefit from real-world reporting examples, Q&A, and expert guidance across specialties to master coding for medical necessity. Learn how to lock in medical necessity and keep your practice safe and profitable: Avoid Medical Necessity Errors with CERT Smarts Rules to Improve Provider Documentation Denials? Pay Attention to Procedure/Diagnosis Linkage Nail Down the Ins and Outs of Time-based Coding Expert Guidance to Fend Off RAC Audits and Denials Beat E/M Coding Confusion with Payer Advice Improve Your ABN Know How with This FAQ

Nonphysician Practitioner Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 14 pages
File Size : 40,7 Mb
Release : 2020-06-30
Category : Medical
ISBN : 9781626889866

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Nonphysician Practitioner Reference Guide - First Edition by AAPC Pdf

Ensure full pay for services provided by your nurse practitioners, physician assistants, clinical nurse specialists, and other mid-level clinicians. Staffing nonphysician practitioners (NPPs) enables your practice to see more patients, but the revenue benefits depend on your team’s ability to navigate the complex set of NPP coding and billing rules. Do you know the guidelines that Medicare and other payers apply toward reimbursement of NPP services? Are you clear on the rules for direct supervision? How about reciprocity? If you’re like most, you have more questions than answers. Getting incident-to billing right means 15% more in reimbursement. Getting it wrong could be considered fraudulent. With stakes this high, you need the Nonphysician Practitioner Reference Guide. This comprehensive resource provides expert guidance covering the scope of NPP coding and billing regulations. Understand the distinctions between shared visit and incident-to services and meet the troublesome requirements of audit-ready incident-to billing. Packed with authoritative tips, readers’ Q&A, and handy clip-and-save tools—including an incident-to audit checklist—you’ll master the reporting nuances of E/M services, prolonged services, virtual visits, and more. Shore up revenue for your mid-level practitioners with: Tips for accurate dual-provider coding Max out incident-to pay the right way and earn 100% of allowable revenue versus 85% Rely on split/shared visit coding in non-office settings Know how to avoid substitute physician billing challenges Boost your signature know-how and avoid claim denials Watch incident-to claims when physician is out of office Get the facts on performing consults Learn the secret NPP guidelines for coding virtual visits Do you know the reciprocity rules when your physician leaves town? And much more! Clear up your NPP compliance confusion—and know exactly when you can bill service incidents to the physician—with the Nonphysician Practitioner Reference Guide.

Denials Management & Appeals Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 16 pages
File Size : 46,5 Mb
Release : 2020-03-17
Category : Medical
ISBN : 9781626889828

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Denials Management & Appeals Reference Guide - First Edition by AAPC Pdf

Recoup lost time and revenue with denials management and appeals know-how. Claim denials can sink a profit margin. And given the cost of appeals, roughly $118 per claim, not all denials can be reworked. A practice submitting 50 claims a day at an average reimbursement rate of $200 per claim should bring in $10,000 in daily revenue. But if 10% of those claims are denied, and the practice can only appeal one, they lose $800 per day—upwards of $200K annually. Your medical claims are the lifeblood of operations. Don’t compromise your financial health. Learn how to preempt denials with the Denials Management & Appeals Reference Guide. This vital resource will equip you to get ahead of payers by simplifying the leading causes of denials and showing you how to address insufficient documentation, failing to establish medical necessity, coding and billing errors, coverage stipulations, and untimely filing. Rely on AAPC to walk you through the appeal process. We’ll help you establish protocols to avoid an appeals backlog and teach you how to identify and prioritize denials likely to win an appeal. What’s more, you’ll learn when a claim can be “reopened” to fix a problem. Collect the revenue your practice deserves with effective denials and appeals solutions: Know how to analyze your denials Defeat documentation and compliance issues for successful claims success Utilize payer policy for coverage clues Lock in revenue with face-to-face reimbursement guidance Refine efforts to avoid E/M claim denials Ace ICD-10 coding for optimum reimbursement Put an end to modifier confusion Stave off denials with CCI edits advice Navigate the appeals process like a pro And much more!

The Clinical Documentation Improvement Specialist's Guide to ICD-10

Author : Glenn Krauss
Publisher : HC Pro, Inc.
Page : 163 pages
File Size : 43,9 Mb
Release : 2011-03
Category : Medical
ISBN : 9781601468178

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The Clinical Documentation Improvement Specialist's Guide to ICD-10 by Glenn Krauss Pdf

Take charge of ICD-10 documentation requirements The implementation of ICD-10 brings with it new documentation requirements that will have a significant impact on the work of your CDI team. The higher degree of specificity of information needed to code accurately will have a direct correlation to reimbursement and compliance. CDI specialists need a firm understanding of the new code set, and the rules that govern it, to obtain the appropriate level of documentation from physicians. The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only book that addresses ICD-10 from the CDI point of view. Written by CDI experts, it explains the new documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. You'll find the specific documentation requirements to appropriately code conditions such as heart failure, sepsis, and COPD. Learn from your peers The Clinical Documentation Improvement Specialist's Guide to ICD-10 includes case studies from two hospitals that have already begun ICD-10 training so you can use their timelines as a blue print to begin your organization's training and implementation. ICD-10 implementation happens in 2013. It's not too soon to start developing the expertise and comfort level you'll need to manage this important industry change and help your organization make a smooth transition. Benefits: * Tailored exclusively for CDI specialists * Side-by-side comparison of what documentation is necessary now v. what will be required starting October 1, 2013 * Timelines to train physicians in new documentation requirements to ensure readiness by implementation date * Strategies and best practices to ensure physician buy-in

Guide to Clinical Documentation

Author : Debra D Sullivan
Publisher : F.A. Davis
Page : 416 pages
File Size : 49,8 Mb
Release : 2018-07-25
Category : Medical
ISBN : 9780803669994

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Guide to Clinical Documentation by Debra D Sullivan Pdf

Understand the when, why, and how! Here’s your guide to developing the skills you need to master the increasing complex challenges of documenting patient care. Step by step, a straightforward ‘how-to’ approach teaches you how to write SOAP notes, document patient care in office and hospital settings, and write prescriptions. You’ll find a wealth of examples, exercises, and instructions that make every point clear and easy to understand.

The Clinical Documentation Sourcebook

Author : Donald E. Wiger
Publisher : John Wiley & Sons
Page : 338 pages
File Size : 52,7 Mb
Release : 2010-02-02
Category : Psychology
ISBN : 9780470527788

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The Clinical Documentation Sourcebook by Donald E. Wiger Pdf

All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

HIPAA Reference Guide - First Edition

Author : AAPC
Publisher : AAPC
Page : 13 pages
File Size : 48,6 Mb
Release : 2020-03-13
Category : Medical
ISBN : 9781626889842

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HIPAA Reference Guide - First Edition by AAPC Pdf

Is your HIPAA compliance program and breach reporting up to date? Over 94% of providers have experienced some form of data breach, and over 50% have had 5 or more data breaches. From phishing campaigns and PHI-containing emails sent to the wrong recipients to unencrypted devices and servers left publicly accessible, the total number of breaches in 2019 outnumbered the previous year by more than 33%, according to research from Risk Based Security. Get comprehensive guidance to implement HIPAA protocols and prevent the fallout of a data breach with AAPC’s HIPAA Reference Guide. Our nationally recognized HIPAA compliance experts lay out best practices and build on case studies to guide you through the dos and don’ts of compliance. We show you how to recognize and lock down your risk areas, including how to: Build and maintain a culture of security Evaluate your vulnerabilities and guard against cyber threats Assess, analyze, and manage your EHR Immunize your workstations Implement HIPAA-compliant use of mobile devices Ensure your BAAs are HIPAA compliant Prepare for community-wide disasters Plot out your practice’s security incident response plan

The Psychotherapy Documentation Primer

Author : Donald E. Wiger
Publisher : John Wiley & Sons
Page : 288 pages
File Size : 40,9 Mb
Release : 2020-11-10
Category : Psychology
ISBN : 9781119709930

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The Psychotherapy Documentation Primer by Donald E. Wiger Pdf

Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork.

Complete Guide to Documentation

Author : Lippincott Williams & Wilkins
Publisher : Lippincott Williams & Wilkins
Page : 454 pages
File Size : 43,7 Mb
Release : 2008
Category : Medical
ISBN : 1582555567

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Complete Guide to Documentation by Lippincott Williams & Wilkins Pdf

Thoroughly updated for its Second Edition, this comprehensive reference provides clear, practical guidelines on documenting patient care in all nursing practice settings, the leading clinical specialties, and current documentation systems. This edition features greatly expanded coverage of computerized charting and electronic medical records (EMRs), complete guidelines for documenting JCAHO safety goals, and new information on charting pain management. Hundreds of filled-in sample forms show specific content and wording. Icons highlight tips and timesavers, critical case law and legal safeguards, and advice for special situations. Appendices include NANDA taxonomy, JCAHO documentation standards, and documenting outcomes and interventions for key nursing diagnoses.

Suggestions to Medical Authors and A.M.A. Style Book

Author : American Medical Association
Publisher : Unknown
Page : 72 pages
File Size : 50,9 Mb
Release : 1919
Category : Authorship
ISBN : STANFORD:36105128932097

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Suggestions to Medical Authors and A.M.A. Style Book by American Medical Association Pdf

The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition

Author : Jennifer Avery,Cheryl Ericson
Publisher : Hcpro, a Division of Simplify Compliance
Page : 0 pages
File Size : 46,8 Mb
Release : 2013-05-07
Category : Electronic
ISBN : 1615692002

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The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition by Jennifer Avery,Cheryl Ericson Pdf

The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition Now in its second edition, The Clinical Documentation Improvement Specialist's Guide to ICD-10 is the only guide to address ICD-10 from the CDI point of view. Written by CDI experts and ICD-10 Boot Camp instructors, it explains the ICD-10 documentation requirements and clinical indicators of commonly reported diagnoses and the codes associated with those conditions. In it you'll find the specific documentation requirements to appropriately code a variety of conditions. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, not only outlines the changes coming in October 2014, it provides detailed information on how to assess staffing needs, training requirements, and implementation strategies. The authors--an ICD-10 certified coder and CDI specialist--collaborated to create a comprehensive selection of ICD-10 sample queries that facilities can download and use to jumpstart their ICD-10 documentation improvement efforts. Develop the expertise and comfort level you need to manage this important industry change and help your organization make a smooth transition. The Clinical Documentation Improvement Specialist's Guide to ICD-10, Second Edition, is part of the library of products and services from the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS members are CDI professionals who share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. Member benefits include a quarterly journal, members-only Web site, quarterly networking conference calls, discounts on conferences, and more. WHAT'S NEW? Completely revised to accommodate changes in ICD-10 implementation dates Dozens of targeted ICD-10 physician queries Updated ICD-10 benchmarking reports BENEFITS Sample ICD-10 queries Specificity requirements and clinical indicators by disease type and body system Staff training and assessment tools TABLE OF CONTENTS Chapter 1: ICD-10 primer Chapter 2: Conventions and Guidelines Chapter 3: Physician queries Chapter 4: CDI target areas Chapter 5: ICD-10-CM/PCS Provider Education