The Documentation Guidelines say social history is:
an age appropriate review of past and current activities.
As auditors, we interpret this to include:
smoking, alcohol and drug use
support system, if relevant
In order to credit social history in a note, any one of those must be reviewed. There is no requirement that all of them are reviewed. There is no description in the guidelines of how extensive the social history must be. Most auditors count it if one of the above are present.
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In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...
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It has been said that the healthcare industry is notoriously slow in terms of technology adoption. One need only look at how convoluted medical coding and billing are to know that it needs a technology injection. Specifically, medical coding and billing software desperately needs artificial intelligence (AI).
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However, this is about ...
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Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.