A question that I get asked repeatedly, that I haven’t taken the time to address in a long time, came up on a webinar that I was doing for orthopedic executives and coders. What happens when a provider sees a patient and then later finds out that they were a resident of a Skilled Nursing…
Just as we have changed professionally post-COVID, our work environments also may have changed or may need to change. In Today’s Take, I’d like to discuss the structural changes that need to take place post-COVID. Recently, Stephanie Allard did an amazing job presenting a NAMAS webinar addressing the organizational structure of your internal audit teams.…
We often spend a lot of time talking about prescription drug management. Today in our “Take” we will spend time addressing over-the-counter medication. This question was submitted to me by Kelly, who works in a dermatology practice, but her question is relevant no matter your specialty. Kelly’s question is about a physician who is using…
In the expansion category of the 2021 documentation guidelines, there’s some information that may be a little confusing that would like to review with you in Today’s Take. On page 23, under Initial Hospital Inpatient or Observation Care, under the New and Established Patient, there’s a paragraph that reads a little confusing: “If a consultation…
Today’s Take is about independent interpretation, and I know we’ve talked about this before, but I think this is one we’ll have to discuss a lot. Recently I got a question about this topic from Tracy (Hi Tracy! I’m glad to answer your question.) So, Tracy explained that her providers are pain management providers and…
How many charts have you guys already audited in 2023? That’s a really big question. I hope you’re already starting to discuss your audit plan for 2023. It’s not too early, and I hope you’ve already started actually auditing charts for 2023. I recently sent out an audit tip that addressed productivity and quality production…
Tough topics and gray guidelines are what we like to cover in these “Takes,” and this one is no exception. Independent Historian did get cleared up somewhat with 2021 guidelines, but there are still some nuances there. 2021 guidelines did bring about a definition for Independent Historian. It cleared up some of that grayness that…
As we begin the new year and our focused training for the 2023 E&M changes and revisions, I’d like to encourage everyone to refocus their efforts on column three of medical decision-making. The header of column three is very specific, and it’s wordy. I think sometimes we fail to notice that because we’re stuck in…
I can’t remember if I’ve recently covered this topic, so one of us (or maybe both of us) may have Deja vu today. We’re still getting inundated with questions about Problems Addressed regardless of the place or type of service, so whether I’ve already covered this topic or not, it bears addressing it again. Cheryl,…
Acute uncomplicated illness or injury requiring hospital inpatient or observation level care As 2021 documentation guidelines are moving into other types and places of service, it’s time to start taking a deep dive! I want to start by looking at some of the implementations that have changed. There were two major new adaptions in the…