When might a plaintiff in a medical malpractice action want a defendant healthcare provider to produce an electronic audit trail, and what proofs might be offered in favor of and against production? A recent case, Vargas v. Lee, suggests some answers.
How to code gastrointestinal conditions with or without bleeding has been a topic of discussion among coding professionals and clinical documentation improvement (CDI) professionals since the publication of the third quarter 2017 issue of the American Hospital Association’s Coding Clinic. Coding Clinic advised coders to apply the “With” guideline associating bleeding to the gastrointestinal condition even when the medical record lacks a causal relationship documented by the physician.
How can we find a way to obtain the information without diverting more clinician energy and taking time away from the patient?
On a daily basis, we read about new apps or devices that may create, store, and transmit electronically stored information (ESI) relevant to the health of an individual. Healthcare providers may be required to reach out to those entities and produce ESI in response to a legal adversary’s discovery requests.
After years of screening mammograms, always with results that came back clear, Nancy M. Cappello, PhD, was shocked to receive a diagnosis of advanced stage 3 breast cancer. The reason the mammography hadn’t found anything sooner, she learned, was because she had dense breast tissue—a term she had never heard until her cancer diagnosis. This post discusses some basics for mammography coding as it may have related to Nancy Cappello’s experience.
Every month, hospital-based health information management professionals must walk the thin line of ensuring adequate revenue is generated from submitted claims while maintaining quality during coding and pre-bill audits.