Organizations often struggle to finalize charts after discharge so they can be coded in a timely manner, but this process can be completed efficiently with direction from HIM professionals and coordination between departments.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Q: I work in long-term care, and I am familiar with the language in HIPAA regulations regarding requests for electronic copies of medical records for a reasonable fee according to community standards. However, my company does not maintain its medical records in electronic form, nor do we presently have the capability of converting our paper records into electronic format.