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Medical Documentation Blog Posts

Four New HIPAA Financial Transactions to Watch in 2016

Neeraj Jain

When the financial transaction rules were written into HIPAA legislation in 2000, the idea was to provide uniform guidance to streamline financial and administrative transactions across the health care spectrum. Unfortunately, the rules were open to broad interpretation, with the result that tasks such as eligibility requests and claim status inquiries were handled according to the discretion of carriers and clearinghouses. 

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Topics: Medical Billing, Medical Documentation

Takling the problem-oriented medical records approach (POMR)

Neeraj Jain

First described in 1968 by Dr. Lawrence Weed, MD, the medical record-keeping system dubbed “Problem Oriented Medical Records”, or POMR, offers advantages to both provider and patients, not the least of which is a more patient-focused approach. However, many physicians object to its use as being too cumbersome, data synthesis restrictions, lengthy progress notes, etc.  However the system’s proponents insist that when used properly, POMR does just the opposite and results in concise, complete and accurate record keeping, especially with reporting and managing chronic care conditions.

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Topics: Medical Billing, Medical Documentation

Understanding the New Medical Necessity Documentation Requirements

Neeraj Jain

Florida was at the forefront of enhanced medical necessity documentation for major joint replacement surgeries when the state's Medicare Administrative Contractors (MACs) issued detailed coverage requirements in 2011. Following Florida's lead, several other states ratcheted up their documentation requirements, and in 2014, HHS Secretary Kathleen Sebelius promulgated similar medical necessity requirements for CMS providers on a national level. 

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Topics: Medical Documentation

Sharing Medical Document Via Document Viewers

Harold Gibson

No matter the industry that your business operates in, it is paramount that you keep your customers' data secure. Data security is especially important within the medical industry where HIPAA guidelines come into effect. From watchdog organizations to governmental regulators, there are strict standards on what types of patient data can and cannot be shared. Fortunately, there are viable solutions available to help remedy any data sharing issues and it comes in the form of document viewers. Here's a closer look at document viewers and their many benefits. 

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Topics: Medical Documentation

Effective Medical Documentation Delivers Better Patient Care

Harold Gibson

What happens when poor record keeping takes place in your medical practice? It leads to both internal and external reports being incorrect, and reviews and investigations will likely be completely failed when poor record keeping is an issue within your practice. Inconsistent nursing records combined with a failure to properly record discussions with patients and family is a recipe for poor patient care. 

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Topics: Medical Documentation

About this blog

A place for physicians and other healthcare stakeholders to share and discover information about everything related to running efficient medical practices.

Established in 2002 by a group of physicians, we are a national provider of medical billing services to group practices, clinics, and individual physicians. We also specialize in provider credentialing, payer contract reviews, and medical coding for a wide range of clients - from solo practitioners to multi-site, multi-specialty practices.

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