Compelling Production of the Audit Trail in Litigation
Apr18

Compelling Production of the Audit Trail in Litigation

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.

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The Gastrointestinal Bleed Conundrum: To Code “with bleed” or Not?
Apr17

The Gastrointestinal Bleed Conundrum: To Code “with bleed” or Not?

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.

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The Relationship between Data and Patient Care
Mar27

The Relationship between Data and Patient Care

How can we find a way to obtain the information without diverting more clinician energy and taking time away from the patient?

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Possession, Custody, or Control: When can a party be required to produce ESI held by someone else?
Mar20

Possession, Custody, or Control: When can a party be required to produce ESI held by someone else?

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.

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Dense Breasts and Coding Mammography
Mar13

Dense Breasts and Coding Mammography

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.

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Maintaining Quality in Financially-Focused Audit Denial Prevention
Feb27

Maintaining Quality in Financially-Focused Audit Denial Prevention

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.

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