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May 2015 Connect with us Facebook Twitter Sign up  |  Archive  |  Advertise
Editor's e-Note
Technology is a wonderful thing—or is it? For the most part, modern-day advances have made our lives both easier and more fulfilling. However, there are times when the latest and greatest gets to become annoying at best, disruptive at worst. (Think automated call centers.)

The transcription industry finds itself facing many questions surrounding the adoption of new technology. This month’s E-News Exclusive addresses where the human element fits into the equation.

Lee DeOrio, editor
e-News Exclusive
Transcription — Should Technology Replace Customer Service?
By Karen Davis

Technology advancements in health care documentation over the past 10 years have been tremendous. EHR solutions have become one of the more prevalent technologies; speech recognition is maturing and becoming more effective as it continues to gain acceptance in medical specialties; natural language processing/understanding has made speech recognition more practical for the average user; and mobile applications have taken patient documentation “on the go” without risking security.

One of the primary goals of using technology to document and transcribe was to improve efficiency and lower costs. Another byproduct—at least according to some health care technology providers—was to eliminate transcription’s human element.

Full Story »
Industry Insight
HIM Company Adds Medical Scribe Services

American owned and operated HIM company, eData Services US recently added Virtual Medical Scribes to its portfolio of health information products and services.

Virtual Scribes are registered nurses trained in medical record documentation, including ICD-10. They provide real-time transcription, documentation, and virtual assistant services to physicians and other health care practitioners.

By utilizing highly secure voice and data systems, and through intensive staff training, eData ensures that patient data handling fully complies with HIPAA and all other state and federal laws. eData can enter information into any EHR/EMR.

Read more »
In this e-Newsletter
Recently in For The Record
CDI Makes Its Mark
While clinical documentation improvement projects enjoy success, organizations must be careful not to spread staff too thin. Read more »

Recording Artists
Inundated with EHR data and complicated regulations, cancer registrars have seen their roles expand significantly. Read more »

What a Patient Wants
Are consumers who ask for health information disclosures actually requesting access? It’s up to providers to educate patients on the differences. Read more »

Marrying Voice and Text Within the EHR
Speech recognition that lives seamlessly with electronic records can make life a lot easier for busy physicians. Read more »
Other News
Baptist Healthcare Bans SSNs
to Reduce Risk, Please Patients

In a move designed to increase security, a south Florida health system has scrubbed Social Security numbers from its electronic records, according to

Police Wait to Tell About Baby Found
at School to Protect Mother’s Privacy

Did the Syracuse police department misinterpret HIPAA in this case reported by
ACDIS Preview
Conference Tailors Education to CDI Professionals
By Heather Hogstrom

San Antonio will be hosting the Association of Clinical Documentation Improvement Specialists’ (ACDIS) 8th Annual Conference May 19-21, with preconference sessions May 17-18. Clinical documentation improvement (CDI) professionals, including CDI specialists and directors, coding compliance specialists and directors, HIM directors, inpatient coders, coding supervisors, and case management directors, will find relevant sessions to enhance their CDI programs.

Read more »
WEDI Preview
WEDI Announces 24th Annual National Conference in Scottsdale, Arizona

The Workgroup for Electronic Data Interchange (WEDI), a nonprofit authority on the use of HIT to create efficiencies in health care information exchange (HIE), announces its 24th Annual National Conference convening top leaders in HIT seeking to engage in strategic discussions about the future of electronic health data interchange. The four-day event will take place at the Talking Stick Resort in Scottsdale, Arizona, from May 18-21, 2015, and will feature an opening keynote presentation from Richard Carmona, MD, MPH, FACS, 17th surgeon general of the United States, on “A Vision of the Future of Technology and Medicine.”

“WEDI’s 2015 National Conference is one of the most innovative, game-changing health care events and continues to spur enormous industry impact year after year,” says Devin Jopp, EdD, WEDI president and CEO. “In addition to Dr. Carmona’s keynote and our stellar lineup of speakers presenting on actionable industry topics, we’re excited to enhance the attendee experience with the conference’s never-before-seen programs and features.”

Read more »
NCRA Preview
NCRA Focuses on Future
By Heather Hogstrom

The National Cancer Registrars Association’s (NCRA) 41st Annual Educational Conference will be held in San Antonio May 20-23. Featuring the theme “On a Mission: Education for a Changing Environment,” the NCRA conference is preparing cancer registrars for changes in the field and making sure they are up to date, including being ready to transition from collaborative stage to directly coded stage. As the conference looks toward the future, Keynote Speaker Clement Bezold, PhD, chairman and cofounder of the Institute for Alternative Futures, has plenty of insight to offer as a “health futurist” and author of several books on the future of health.

Read more »
Featured Jobs
The nation's top employers and recruiters of HIM talent advertise in For The Record magazine and post their job openings on Check out the most recent opportunities that have been submitted by employers across the country!

Coding Auditor—M*Modal, Remote (Telecommute)
Full-Time Coder—Owensboro Health, Owensboro, KY
Full-Time HIM Coder/Abstractor—Hospital for Special Care, New Britain, CT
Certified Cancer Registrar—Dana-Farber Cancer Institute, Boston, MA
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Ak the Expert
Have a coding or transcription question? Get an expert answer by sending an e-mail to

This month’s selection:
If a patient did not have a documented injury but developed back pain a month ago and now is being seen for back pain, and the doctor dictates that the diagnosis is a “musculoskeletal strain of the low back,” should we be using the 800 code or a disorder of muscle code such as 728.3, the disorder of back code 724.9, or some other code?

Lisa Lynch, CCS-P, COSC
Mankato, Minnesota

You need to code as a strain because that is what is being documented by the treating provider. To locate the correct ICD-9 code, look up strain in the Index to Diseases. You are referred to see also Sprain, by site. When you go to sprain, low back, you are referred to 846.9, or sprain, lumbar (spine), you are referred to 847.2. Review the codes in the tabular list to determine which code is most appropriate for the patient.

— Raemarie Jimenez, CPC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, is vice president of member and certification development at AAPC.
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Tech & Tools
MS-DRG Decision Support Tool
Increases Claims Accuracy

Wolters Kluwer Law & Business has partnered with New Health Analytics to develop a stand-alone MS-DRG Grouper, Calculator & Analyzer. Created to increase claims accuracy, the MS-DRG Grouper, Calculator & Analyzer provides the opportunity for consultants, cost report analysts, product line managers, and regulators to perform a comparative analysis of multiple providers’ Medicare Expected Payment. It allows users to compare and benchmark national, state, regional, and provider-specific reimbursement for any MS-DRG; reveal the impact of performance on measures like quality reporting, meaningful use, and readmissions; and identify outlier eligibility and calculate payment increase. Learn more »

Smartphone Breathalyzer Detects Diseases
A research consortium is developing a product that, when coupled with a smartphone, will be able to screen the user’s breath for early detection of life-threatening diseases. The SNIFFPHONE project will link breathalyzer screening technology to the smartphone to provide noninvasive, fast, and cheap disease detection. Micro- and nano-sensors read exhaled breath and then transfer the information through the attached mobile phone to an information-processing system for interpretation. The data are then assessed and disease diagnosis and other details are ascertained. Learn more »

Sutter Health Debuts Mobile App
Sutter Health has debuted a new, free mobile app for iPhone, iPad, and iPod touch designed to provide current and prospective patients more convenient, anytime access to its network of care and services. Features include Symptom Checker, which helps users make informed decisions about their health, including what level of care to seek; My Health Online, a secure online site where patients may access their health information, e-mail their physician’s office, request appointments, view test results, and pay bills; and consults with physicians via phone or video through telehealth provider MDLIVE. Learn more »

3M 360 Encompass MD Boosts
ICD-10 Documentation Accuracy

With computer-assisted physician documentation guidance, automated clinical documentation improvement queries, and a sophisticated “copy-paste” analysis tool, the new 3M 360 Encompass MD System makes it easy to capture accurate patient information, meet ICD-10 documentation requirements, and minimize compliance risk—all in real time as the physician documents within the EHR. 3M 360 Encompass MD integrates with all major EHR systems to analyze available patient data—including EHR templates and dictated documents—and then identifies unclear, unspecified, or missing diagnoses and gaps in documentation. It helps physicians prepare for ICD-10 by prompting them for more specificity as they are documenting and when more information is required to meet coding guidelines. The intelligent copy-paste analysis tool, scheduled for release in late summer 2015, differentiates between appropriately copied content from prior notes and content that is high-risk for compliance and should be reviewed by the physician. Learn more »
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