My experience in ICD-10-CM documentation and coding integrity is that many physicians know in their heads what is wrong with their patients; however, they have not been taught to “think with ink” in describing their patients' illness in the EHR using ICD-10-CM’s language to ensure proper coding.
Having just witnessed nature wreak havoc with back-to-back hurricanes, I feel it’s important to take a few minutes to remind everyone of the importance of Plan B—the backup plan. Let’s look at some real examples of how HIM professionals can be proactive to prevent chaos when unexpected events occur.
RC.01.01.01 is one standard that just won’t go away. The first half of 2017 (January–June) standards compliance data was published in the September issue of The Joint Commission’s Perspectives, and RC.01.01.01 made the list again. This means that the standard has been on the top 10 list for at least the last five years, along with other frequent flyers such as Environment of Care, Life Safety, and Infection Prevention.
Access to protected health information (PHI) is one of the most important rights individuals and their personal representatives have under the privacy regulations, but this right is not absolute.
Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.
