Our readers have been asking for an updated medical record documentation guide, and here it is?new and improved! The guide provides references to the associated CMS Conditions of Participation and new and revised standards and elements of performance (EP). A recent Joint Commission column discussed ongoing record reviews and the continued focus of Joint Commission surveyors related to documentation in the medical record. The guide takes the Record of Care, Treatment, and Services chapter and breaks it down into an easy-to-use tool for comprehensive record reviews by topic.
In February 2016, just four months after ICD-10 go-live, sister publication HIM Briefings (formerly Medical Records Briefing) asked a range of healthcare professionals to weigh in on their productivity in ICD-9 versus ICD-10.
The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.
In celebration of our 30th year of delivering you the latest in HIM, we continue to reflect on what HIM was like 30 years ago, examine today's HIM landscape, and look to the future.
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
Approximately 800 hospitals across the country that perform inpatient total hip and knee joint replacements will be required to participate in the latest value-based payment initiative launched by CMS, the Comprehensive Care for Joint Replacement (CJR) model, which becomes effective April 1.
A recent Healthcare Financial Management Association webinar on the CJR noted it as one of the biggest Medicare changes since the implementation of diagnosis-related groups (DRG). Not surprisingly, various impacted parties continue to push for delays in implementation of the model. The CJR model holds participant hospitals financially accountable for the cost and quality of an episode of care and incentivizes increased coordination of care among hospitals, physicians, and postacute care providers.
The assignment of ICD-10 codes on both inpatient and outpatient claims impacts these outcomes by triggering which discharges are included in the program, the actual (or observed) complication rates for these patients, and?equally important but often overlooked?their risk-adjusted expected complication rates. If ever there was an opportunity for clinical documentation improvement (CDI) programs to step up to support their organizations with documentation that impacts both quality and financial outcomes, this is it!
