I was reading an article today about healthcare reform and the affordable care act, which linked an increase in CDI staff with the increased use of electronic health records. I began to reflect on the past 10+ years in the Clinical Documentation [...]
Electronic health records continue to be instituted within hospitals in order to more efficiently capture the documentation of the patient story. In a recent article “Clinical Documentation in the 21st Century” we hear the position of the ACP (American [...]
As of January 1, 2015, the AMA is overhauling a select group of presumptive testing laboratory CPT codes. This shift moves us from a structure based on an identifying code for type of test performed to one that groups like tests based on number performed [...]