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.
Now that fall is in the air, hospitals may feel a chill as Medicare implements the Patient Protection and Affordable Care Act (PPACA) through the 2011 inpatient prospective payment system. Aspects include:
The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and installing a new encoder.
