Out with the 95/97 Evaluation and Management (E/M) guidelines, in with the new and improved 2023 E/M guidelines - Sounds easy right!? While the intent to reduce provider documentation burden may have been accomplished, the learning curve for providers and coders is real! Don’t get me wrong, there are several advantages to the updated guidelines; however, there are still rules that seem more difficult to follow than they should be. Not to mention breaking out of habits developed since 1995! While there are a couple of new E/M guidelines that have me scratching my head, today I would like to cover the confusion of how and when to count the review and analysis of tests.

Have you ever considered utilizing Learning Management Systems (LMS) in your organization? As global connectivity has grown, there has been an ever-greater need for a way to distribute educational courses and other programs to a widespread digital audience. Out of this need grew Learning Management Systems, or L.M.S., a software application created for the documentation, tracking, reporting, and delivery of educational courses, training programs, and learning and development programs.

While it seems initial coding audits have become a common practice among healthcare organizations, the importance of continued and ongoing auditing has become lost and forgotten. Keeping up with ongoing auditing is crucial for any healthcare organization as this can prevent revenue from being lost and the amount of unwanted and unnecessary denials from increasing. This also gives healthcare organizations a chance to educate their coding specialists and identify if their coding qualities align with their organization’s quality standards.

Wouldn’t it be perfect if your healthcare organization contained clinical documentation improvement (CDI) specialists that had both a coding background and a clinical background? However, trying to find a person with that background is like finding a needle in a haystack. Most healthcare organizations have a team that contains CDI specialists who are also RNs and a team that contains coding specialists with coding credentials.