Health Language Blog

Four Reasons Healthcare Organizations Need to Simplify the Documentation of the Clinician Diagnosis Process

Posted on 10/25/16 | Comments

Finding and selecting the right diagnosis code is critical to both patient care and revenue cycle management. The downstream negative impact of using an unspecified code can touch everything from decision support to reimbursement, compliance, and reporting. In addition, unspecified codes are not as useful for other clinicians needing to review the records and for patients themselves as they review their own records.

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Topics: ICD-10, clinical documentation, PFT, reinburment, unspecified codes, revenue cycle management, provider friendly terminology, cdi, clinical codes

Hierarchical Condition Categories Part 1: What’s all the Buzz About?

Posted on 07/13/16 | Comments

There is quite a bit of discussion around Hierarchical Condition Categories (HCCs) these days. And for good reason: as the risk adjustment model used since 2004 to determine reimbursement for various Medicare plans, the HCC framework is progressively being applied to numerous healthcare reform initiatives. In this two-part series, we break down the basics of HCCs, why they matter and how all healthcare stakeholders should respond to them going forward.

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Topics: clinical documentation, HCCs

How a Terminology Platform Can Support an EHR

Posted on 02/05/13 | Comments

Vocabulary standards are playing a key force in enabling interoperability of patient data. Meaningful Use may be accomplishing what hasn’t happened before – a set of rules everyone will follow to allow patient data to flow between EHR systems, delivery networks and regional organizations.  Whether the vocabulary standard is a classification system, terminology, controlled vocabulary, or nomenclature, a terminology server can provide a range of services to use and manage these complex entities. 

Vocabularies named to achieve Meaningful Use have been thought of as fairly fixed and simple entities needing little care and feeding. As organizations begin to implement these vocabularies, the complexities of the concepts and relationships become apparent. 

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Topics: Meaningful use, clinical documentation, Analytics

SNOMED: What it is and Why it was Added to Stage 2 Meaningful Use

Posted on 01/25/13 | Comments

For many years providers have been doing a good job of summarizing their patients’ current and relevant medical conditions on a “problem list”.  Typically this list is located within the first page of a patient’s chart, ideally enabling the medical provider to quickly assess the current and past medical issues of the patient.  While the intent is clear, the methodology is not – many providers still using paper charts may use acronyms to express a clinical condition (e.g. MS or AA) or they may not add the date of the diagnosis and/or its resolution.  For those providers who utilize EMRs (electronic medical records) the problem may be more complex due to the lack of interoperability between different EMR systems. 

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Topics: Meaningful use, SNOMED, clinical documentation