RMC’s Blog

Tiresome But Oh-So-Necessary Audit Log Monitoring

Audit log monitoring is probably one of the most unsexy, uninteresting activities a healthcare organization or business associate has to do.  But neglect it at the risk of your solid bottom line and reputation. Last time we talked about how you can get into legal...

Infusions, Injections and Hydration

Certain elements of documentation must be present to code infusions, injections, and hydrations     properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration...

Medical/Clinical Coding for Additional or Secondary Dx

Throughout my career in Health Information Management, one of the particular areas of focus for both auditing and education has been the coding of an additional or secondary diagnosis. Whether inpatient (acute care) or outpatient coding, confusion and even errors...

OIG: Medicaid Fraud Control Units 2020 Report

Medicaid provides coverage and healthcare services with federal and state funding to 72.2 million people in the Unites States. This coverage is for those with limited income and resources i.e., low-income adults, children, pregnant women, elderly adults, and people...

CPT Releases New COVID-19 Vaccine Code

We all are aware of the currently available COVID-19 vaccines from AstraZeneca, Janssen (Johnson & Johnson), Moderna and Pfizer and their unique CPT® codes. These medical codes allow for each vaccine and immunization administration to be clinically distinct,...

SDOH . . . Value and Importance Continues to Grow

Over the past year we have seen and read more and more about the reporting of Social Determinants of Health or “SDOH". Clearly there has been a COVID-19 impact to the overall interest in these social economic and psychosocial aspects of an individual. More research...