Clinical Documentation

From Pilot to Scale, Mount Sinai Leverages Autonomous Medical Coding

February 12, 2024 - An experiment to streamline medical coding is set to take off at Mount Sinai Health System. The academic medical system nestled in the New York metropolitan area recently implemented autonomous medical coding within its pathology department to streamline coding and bring efficiencies to care delivery. Now, the technology codes about half of the system’s pathology cases, with...


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What Payment Integrity Means for Providers, How to Avoid Claim Issues

by Jacqueline LaPointe

Healthcare providers are constantly running into payment integrity tools payers put in place to ensure proper payment. But payment integrity is also crucial for providers if they want accurate, complete, and timely reimbursement. Of the...

CPT Code Set Adds Code for J&J COVID-19 Vaccine Booster

by Jacqueline LaPointe

The American Medical Association (AMA) has updated the Current Procedural Terminology (CPT) code set to include a new code for COVID-19 vaccine booster doses of the vaccine created by Janssen...

How E/M Coding Changes Became an Urgent Problem for a TN Clinic

by Jacqueline LaPointe

The past year has been tough for AFC Urgent Care Memphis, Tennessee. Like most practices, the small urgent care clinic saw patient volume dip dramatically at the start of the COVID-19 pandemic. And like their peers, this all happened...

2022 CPT Code Set Released, Streamlines Medical Coding for COVID-19

by Jacqueline LaPointe

The new 2022 Current Procedural Terminology (CPT) code set aims to streamline medical coding and documentation of COVID-19 vaccinations, among other updates. The code set released today by the...

Moving to the Future of Clinical Documentation Improvement

by Jacqueline LaPointe

Clinical documentation has come a long way since the days of paper medical records. Widespread adoption of EHR systems and now EHR optimizations have modernized the act of clinical documentation, and...

Clinical Documentation Improvement Vendors Gaining Momentum

by Jacqueline LaPointe

The clinical documentation improvement (CDI) vendor landscape has undergone significant changes over the last couple of years, including vendor acquisitions and technology developments. And these...

Top Challenges, Opportunities of Medical Coding and Billing

by Jacqueline LaPointe

By April of last year, seemingly every news station in American was featuring the heroic efforts of physicians, nurses, and other clinicians fighting COVID-19. These providers transformed healthcare, implementing telehealth and virtual...

Clinicians, Tech Help St. Joseph’s Health Increase Charges by $39.6M

by Jacqueline LaPointe

Beth Kushner, DO, always starts lectures with residents at St. Joseph’s Health with a simple philosophy. “You should get paid for everything you do, nothing you didn't do, and make...

AMA Creates CPT Codes for AstraZeneca’s COVID-19 Vaccine

by Jacqueline LaPointe

In anticipation of an emergency use authorization from the Food and Drug Administration (FDA), the American Medical Association (AMA) has created Current Procedural Terminology (CPT) codes for...

AMA Updates CPT Code Set to Include COVID-19 Vaccine Codes

by Jacqueline LaPointe

The American Medical Association (AMA) has added several COVID-19 vaccine codes to the Current Procedural Terminology (CPT) code set so providers can report immunizations for the novel...

3 Ways to Improve Medical Coding Quality for Accurate Reimbursement

by Jacqueline LaPointe

While some have said medical coding sits quietly in the middle of the healthcare revenue cycle, it is a key step that, when done inadequately, can impact each part of the revenue cycle after it....

AMA Announces New CPT Codes for Coronavirus Testing

by Jacqueline LaPointe

The American Medical Association (AMA) recently expanded its Current Procedural Terminology (CPT) code set to include four new CPT codes for coronavirus testing, according to a special coding guidance...

Appeals Court Nixes Fraud Case Against Baylor Scott & White Health

by Jacqueline LaPointe

Texas-based Baylor Scott & White Health has again beat a False Claims Act lawsuit alleging that it inflated medical codes in order to maximize Medicare reimbursement. On May 28, the US Court of...

What Providers Need to Know About COVID-19 Coding and Billing

by Jacqueline LaPointe

The COVID-19 pandemic is putting strain on the healthcare system, but accurately capturing data and documenting cases of the novel coronavirus can help ease the burden on providers. For more...

CAQH CORE Approves 2-Day Limit for Prior Authorization Response

by Samantha McGrail

CAQH CORE recently voted on a new rule to set a two-day time limit to speed up the prior authorization process, according to a recent press release. Under the new rule, CAQH CORE participating...

Providers Ready for AI Clinical Documentation Improvement Tools

by Jacqueline LaPointe

Forty-four percent of healthcare organizations already use artificial intelligence (AI) in one form or another, and more hospitals are looking to apply the technology to coding and clinical...

Hospital Upcoding Behind Increase in Inpatient Spending in MA

by Jacqueline LaPointe

Higher prices and hospital upcoding drove the nearly 11 percent increase in commercial inpatient spending in Massachusetts, according to a new preliminary report from the Health Policy Commission...