MTS Transcription Services: Resources

Medical Documentation Tips to Address RAC Audits

The Centers for Medicare and Medicaid Services (CMS) closely scrutinizes hospitals and physicians to identify healthcare fraud and abuse. The actual target is not the quality of care, but the documentation that supports why a particular service or procedure was offered. CMS has contracted various organizations, collectively known as recovery audit contractors or RACs to … Continue reading Medical Documentation Tips to Address RAC Audits

Documentation Requirements for Annual Wellness Visit

The Annual Wellness Visit (AWV) is a yearly appointment that provides the opportunity for healthcare providers to develop and update a personalized prevention plan for their patients. Medicare covers Annual Wellness Visit if the patients have had Medicare part B coverage for more than 12 months and have not received an initial preventive physical exam … Continue reading Documentation Requirements for Annual Wellness Visit

EHR for Clinical Notes – An Analysis

Clinical notes are records that summarize the interaction between patients and healthcare providers, and are central to patient care. These may include notes from outpatient visits, inpatient admissions and discharges, procedures, protocols, and testing results. The process of documenting clinical care covers the diverse domains of patient care, clinical informatics, workflow, research and quality. As electronic health records (EHRs) are widely used by providers now, there is growing emphasis on structuring clinical notes to reuse data for subsequent tasks. However, generating clinical notes for an electronic record system is a challenging task.

Pediatric Documentation for ICD-10

Being a specialty that already has a low financial margin, pediatric practices must ensure increased specificity in the documentation of their findings to avoid financial setback just after ICD-10 implementation. If pediatricians continue to follow the same documentation practice they have been following, the diagnoses will map to unspecified codes that may not be reimbursable. Most of the diagnoses require much more specific details in ICD-10-CM. Pediatricians should specify the episode of care and laterality, give more details of the location of an injury or condition and clearly indicate the presence of the symptom, manifestation or complications in their documentation. Let’s take a look at the additional documentation required for pediatric diagnoses.

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