Practice Management
Rhode Island recently became the first state with a law specifically aimed at ambient AI scribes, requiring disclosure to patients when scribes are used and provision of an opt-out process. State law also says the provider must review any AI-generated documentation for accuracy. Only a small number of states have enacted laws that specifically require healthcare providers to disclose the use of ambient AI tools during patient encounters. A few others rely on broader AI …
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Urgent Message: Quality improvement projects can increase the percentage of charts closed within 1 hour of patient discharge at pediatric urgent and express care locations to ensure timely documentation. Key Words: Electronic Health Records, Documentation, Pediatrics, Ambulatory Care, Patient Safety, Quality Improvement Kileen Fernandez, MS, APRN-CPNP-PC; Lisa Ziemnik, MD, FAAP; Beth Williams, MBA, BSIE; Abiodun Omoloja, MD, MBA, CPE, FASN, FAMIA; Jennifer Morris, MS, APRN-CNP-PC, RNC-NIC; Maddie Mock, BSME; Thomas Geglein, BSN, RN, MBA; Kimberly …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Urgent care operators face increasing challenges from payer reviews—a situation exacerbated by ongoing confusion around coding guidelines and proper documentation of medical decision-making (MDM). As more urgent care providers grapple with administrative burdens and financial pressures, understanding how to document and code accurately has never been more important. The Rise of Payer Reviews Pre-payment reviews have become commonplace, initiated when a provider’s billing patterns—such as a higher frequency …
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Brad Laymon, PA In the dynamic environment of urgent care (UC) medicine, precise, and thorough documentation serves as a cornerstone for both clinical and operational success. Beyond merely fulfilling regulatory requirements, documentation excellence has 3 critical functions, which I refer to as the “trifecta:” 1. Improved patient outcomes through clear communication of care; 2. Mitigation of malpractice risk through clear and defensible explanation of medical decision making (MDM); and 3. Accurate description of complexity to …
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We are deep into the fourth quarter of 2024, and you are probably preparing for the holidays and wrapping up year-end projects. As we celebrate the end of the year, it is important to also look ahead and lay the groundwork for revenue cycle management success in 2025. Following are some points to consider in your strategic plan for next year. Contract Renegotiations Understanding your payer agreements and your patient population will be instrumental to …
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Download the article PDF: Six Tips to Bulletproof Your Chart: Lessons from the Exam Room and the Court Room Urgent message: In the event that you are taken to court over care that is alleged to have been insufficient, negligent, or otherwise poor, your own documentation at the time care is provided can be your saving grace or your undoing. William Sullivan, DO, JD INTRODUCTION Providing proper medical care in urgent care centers is only …
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Urgent message: By the time an adverse outcome occurs in the urgent care center, it’s too late to go back and ensure the documentation reflects the care the patient received. Lyndsie Pfeifer, DO; Marta Fratczak, Kinkela Harkins, and Michael Weinstock, MD Citation: Pfeifer L, Fratczak M, Harkins K, Weinstock M. Back pain, an urgent care visit—and a devastating outcome. J Urgent Care Med. 2023;17(8):13-17. Key words: back pain, documentation INTRODUCTION It’s easy to let our …
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