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Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [ 1][ 2] Documenting patient encounters in the medical record is an integral part of practice ...
The Health Insurance Portability and Accountability Act of 1996 ( HIPAA or the Kennedy – Kassebaum Act[ 1][ 2]) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President Bill Clinton on August 21, 1996. [ 3] It aimed to alter the transfer of healthcare information, stipulated the ...
Medical classification. A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as ...
The ICD-9/ICD-10 Comparison Utility allows for the analysis of the 837 claim file, providing a snapshot of current billing with ICD-9 and the impact of changing to ICD-10 codes. Additionally, the ...
3M Introduces ICD-10 Physician Education Web-based curriculum trains physicians to capture complete and accurate ICD-10 documentation SALT LAKE CITY--(BUSINESS WIRE)-- 3M Health Information ...
Clinical Coder. A clinical coder —also known as clinical coding officer, diagnostic coder, medical coder, or nosologist —is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information ...
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