For The Record May, 2018
Industry professionals weigh in on the challenges and opportunities of marrying clinical and billing documentation in EMRs.
The foundational objective of any clinical documentation improvement (CDI) program is to produce the most complete and accurate documentation possible. It seems a reasonable goal, yet the industry at large continues to struggle with achieving a balanced documentation product that adequately supports both billing and clinical information needs.
Widespread use of EMRs provides an effective way of collecting data, but it also introduces challenges, according to Mark Morsch, vice president of technology with Optum. “While the EMR has provided numerous benefits to the health care market, the goal of improved documentation and automated coding derived from that documentation has not yet been fully...
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