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Seven Criteria for High Quality Clinical Documentation + Best Practices for Physician Auditing – Combo
Recorded Webinar
Clinical documentation is the cornerstone for all patient medical records. This information should be of the highest quality to allow for optimal patient outcomes as well as supporting research, medical coding and other uses of the medical record. Its purpose is to adequately relate the patient’s current and historical conditions and treatments with primary focus placed on situations that affect the current medical encounter. It also supports the provider’s defense should the case become a legal issue.
Review of 7 criteria that all entries in the medical record should include
Impact of documentation on coding & claims
Establishing a CDI team
The ICD-10 code set requires explicit documentation of conditions & treatments in order to support the severity of patients under treatment as well as allow for the significant specificity required by this code set. Ambiguous documentation and generic coding will no longer guarantee reimbursement and may generate a claims denial for lack of medical necessity. In this session, we will review the theory of high-quality clinical documentation which has the support of healthcare regulatory guidelines and peer-review research.
Additional consideration involves medical outcomes that may result in legal action. When clinical documentation is vague, missing key elements and conflicting statements, the provider may find that he/she is handicapped in supporting medical decisions and patient results, particularly when the result is a negative outcome for the patient.
In today’s healthcare environment, many patients have become educated consumers of medical services. They are more inclined to request their own medical record, carefully review explanation of benefits from payers, and request a review of any information they deem to be incomplete or questionable.
Is your practice audit safe? Do you have compliance risks? The first issue will be where do you start to determine your risk. Some key questions to ask: Is this a compliance or educational audit? Is this a baseline audit or a more focused audit? Do you have an internal audit team or do you need to hire external auditors? The type of audit will determine where to start, how many services to review and the type of service(s) to be audited. Is there a time limitation? Has there been a previous audit that showed issues that need attention? Have there been internal or external complaints that need to be reviewed? This webinar will discuss best practices and all of these issues as well as how to determine a pull and how many services should be included in the audit.
Venue: Recorded Webinar
Turn bad data into great data in minutes! Do you spend more time than is necessary importing and updating data from external sources such as databases, CSV files and web pages? Does the phrase "it's taking too long" describe how you feel about the time it takes to get your data into the right format for your reports? Do you regularly perform repetitive time-consuming "data cleaning and transforming" tasks such as removing unnecessary rows and columns, filtering out data that you don’t need, converting text to numbers or dates, splitting or merging columns, removing "weird" characters or combining files together? Would you like to be able to do all the above with the click of a button? If the answer Is yes, you need Power Query (known as Get and Transform in Excel 2016 and later). This training will focus on two main topics…How to import data into Excel from a variety of sources and how to automate the data cleaning process. Why you should attend Power Query / Get and Transform can save you a ton of time when working with imported data. In many cases when you get data from external sources, it needs work on it before it can be used. Although this can be done using Excel functionality, Power Query / Get and Transform is a lot faster and is repeatable with a couple of clicks. Topics covered Import data into Excel from sources such as text files, web pages and databases Avoid Excel’s "million-row limitation" Keep the imported data in sync with the source data using just two clicks Understanding and Managing Steps in the Power Query Editor Save a ton of time - automate the data cleaning process Who should attend? This training is classed as intermediate and is aimed at users of Excel who wish to learn about Power Query/Get and Transform to clean data (as both a one-off and a repeating process)
The Biden-Harris Administration, through the Office for Civil Rights (OCR) at the U.S. Department of Health & Human Services (HHS) has issued a Final Rule to modify the HIPAA Privacy Rule to support reproductive health care privacy. This Final Rule is one of many actions taken by HHS to protect access to and privacy of reproductive health care after the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization that has led to extreme state abortion bans and other restrictions on reproductive freedom in 21 states. To better protect information related to reproductive health care and to bolster patient-provider confidentiality, organizations providing these services will need to implement required changes. This webinar will review those changes and provide guidance on new HIPAA Privacy Rule requirements. Webinar Objectives Definitions, Rules, CFR, & Acronyms What is Protected Health Information? Understand the Prohibitions Understand the Presumptions Understand Attestation Requirements Needed Changes to Your Notice of Privacy Practices Understand Disclosures to Law Enforcement The Complaint Process Q&A Webinar Highlights Learn from an expert who has served as a HIPAA Compliance Officer in a large organization. Learn how to understand the HIPAA Privacy Rule Final Rule to Support Reproductive Health Care Privacy. Learn what PHI can be disclosed to whom. Who Should Attend Compliance Officer HIPAA Privacy Officer HIPAA Security Officer Practice Managers Information Systems Manager Chief Information Officer General Counsel/lawyer Practice Management Consultants Reproductive Health Providers Women’s Healthcare Providers Vendor Business Associates supporting these providers
Confused about HIPAA compliance requirements and how it applies to your organization? HIPAA can be complicated!! Knowing what an organization must have in place to meet regulatory requirements can be challenging. For anyone tasked with managing a HIPAA compliance program, understanding the HIPAA security and privacy management process is critical to implementing and maintaining a comprehensive compliance program. The webinar will look at specific challenges organizations face in meeting HIPAA compliance requirements. This will include risk management plans; risk assessments; and program management. A growing concern with healthcare data is cybersecurity threats. The webinar will review critical HIPAA related information security topics. After completing this webinar, a Covered Entity or Business Associate will have a clear understanding for how to meet the growing demands of HIPAA compliance. Webinar Objectives Definitions, Rules, CFR, & Acronyms Who Must Comply with HIPAA Requirements? What are the HIPAA Security and Privacy Rules? Challenges of HIPAA Compliance What is a HIPAA Risk Management Plan? Upcoming changes to the HIPAA Privacy Rule How to prevent HIPAA data breaches from occurring Q&A Webinar Highlights Learn from an expert on the implementation of the HIPAA rules Learn what the HIPAA management process requires Learn how to uncomplicate and be able to evaluate your organization’s HIPAA compliance program Who Should Attend Compliance Officer HIPAA Privacy Officer HIPAA Security Officer Medical/Dental Office Managers Practice Managers Information Systems Manager Chief Information Officer General Counsel/lawyer Practice Management Consultants Any Business Associates that access protected health information
ICD-10-CM updates for 2025 will become effective on October 1, 2024. These updates will include several guideline changes as well as multiple updates & additions to the specific chapters. This webinar will discuss the new guidelines as well as specific code categories in which you need to be alert to changes that may impact your code selection. All chapters will be included to ensure your specialty is covered. It is impoprtant that you be proactive and prepared when submitting your claims with discharge dates of October 1. Missed update information may cause a processing & reimbursement delay. Webinar’s Goals Be aware of guideline changes Learn about chapter specfic additions & updates Ensure you are prepared with new code information Align with your software vendors to implement any necessary changes Target Audience Revenue Cycle Managers & staff Billers Coders Clinical Documentation Staff Finance Managers Denial Management Staff Physicians Mid Level Providers Claims Follow Up Staff