“In my opinion, [ICD-10 implementation] is the biggest change in healthcare since the implementation of DRGs back in the early ’80s,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. McCall and Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, spoke during HCPro’s November 18 audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.”
It’s the end of the year, and many of us have been on the fast track to EHRs and EDMS installation, so we pause this month for a little levity and to honor all those working so hard behind the scenes. Happy holidays to all the brave health information professionals continuing to blaze the paths of progress in automated medical record documentation!
We went to medical school. We studied, and many of us learned about pathogenesis of diseases. We were encouraged by our attendings and throttled by our chief residents to be able to spout off the causes of conditions. It wasn’t enough to name the condition; we had to know the myriad possible etiologies. Being quizzed made us sharp. We started to learn patterns and became better diagnosticians because we could digest the complexities of a patient while we did the history and physical. And we knew, even before lab tests came back, what was going on with the patient and how it got there.
Present-on-admission (POA) indicators, hospital-acquired conditions (HAC), and never events have been around for a while. However, they still seem to cause compliance conundrums, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Marblehead, MA.