The practice of medicine is undergoing dramatic changes regarding the importance of communication of healthcare provided. Clinicians today must not only document appropriate severity of illness, but justify medical necessity within the medical record so that third-party payers are aware of efficiency, effectiveness and quality of care being provided. With the implementation of ICD–10 it is even more relevant to document the increased degree of specificity that is required of this complex language.
Not only is our quality of care measured, but revenues / reimbursement for care are dependent upon appropriate capture and justification for all services provided. This program will present the mechanics of clinical documentation for the remainder of ICD-9, as well as in preparation for ICD-10 implementation. The importance of principal and secondary diagnoses, and the capture of all relevant chronic /acute clinical diagnoses, for medical / surgical patients will be presented in a highly interactive workshop. This session could significantly impact the communication of your practice of medicine as well as appropriate reimbursement from third-party payers.