CMS proposes aligning its conditional packaging modifiers and deleting a much-maligned modifier for separately payable laboratory tests in the 2017 OPPS proposed rule, released July 6.
When compared to data from past surveys, HCPro's 2016 HIM director and manager salary survey revealed a harsh truth that many HIM professionals already know: There has been little movement in HIM manager and director salaries over the years.
My HIM career began like many others?in frank conversation with a high school guidance counselor regarding career direction. I wanted to pursue a career in healthcare, but wasn't interested in direct patient care. Focused exploration led me to discover a degree in health information technology at my local college. Now, 30 years later, I'm celebrating a long and successful HIM career.
This column is devoted to restraint and seclusion documentation; it provides support for, and a tool for, 100% review of patients in restraints and/or seclusion.
The Joint Commission and CMS have a common goal of reducing the use of restraints and seclusion in hospitals. Hospitals have come a long way in meeting this goal, and requirements for improvement (RFI) usually are received because of poor documentation in the medical record. Generally, recommendations result from lack of physician orders, physicians not seeing patients on-site, incomplete orders as to the reason for restraints and/or seclusion, and care plans not including the goal to remove patients from restraints and/or seclusion.
Often during surveys, there will be no patients in restraints or seclusion and the surveyors will ask for closed records to review. Once the medical record is closed, little can be done to correct documentation. Therefore, a solid open record review is essential to avoid recommendations.
A process for reviews
Review of open records of patients in restraints and/or seclusion can be performed in several ways. Of utmost importance is the development of a method to identify patients in restraints and seclusion on a daily basis, and to review new and recurring patients until they are discharged. For example:
1.Nurses, clinical documentation specialists, and tracer teams (plus others?) can review medical records each day to ensure documentation compliance
2.If the hospital has an EMR, HIM staff can review open records online to identify discrepancies in documentation and report back to each unit
3.HIM and IT staff can collaborate to develop a method of importing information directly from the EMR to identify documentation errors
Any of these methods should eliminate errors as long as they are corrected as soon as possible before patients are discharged.
Certain phrases just stick with you. The longer you reflect on an idea, the more inspired you are by the ways in which the concept can become relevant to your needs.
CMS issued a final rule last week to revamp the way it pays for tests under the Clinical Laboratory Fee Schedule (CLFS), though the agency has pushed the start date back a year and worked to ease administrative burden based on public comments.
If CMS’ late April release of a change request requiring reporting of the previously optional modifier -JW (drug amount discarded/not administered to any patient) by July 1 seemed too sudden, the good news is many other providers—and the agency—agreed.
CMS' coding modifiers are not always used to report clinical components of a service. Sometimes they can be used in order to provide information about how a service relates to Medicare coverage policies.
CMS is expected next week to discuss potential changes to 2-midnight rule audits by Quality Improvement Organizations after quietly suspending the reviews in early May.
The healthcare industry is focused on the triple aim: reducing healthcare costs, improving patient experience, and improving the health outcomes of populations. Healthcare organizations will no longer be paid based on the volume of services provided but rather on the value of care delivery.
