Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of the revenue cycle.
This due digilence checklist will help track and evaluate document requests, warn of privacy and security issues, and provide a basis for determining action plans and resources required to integrate privacy and security programs.
With value-based reimbursement, providers now must shoulder the health of the patient no matter where the patient receives care. The ability to share patient information seamlessly between these entities using interoperable technology is the next evolution of healthcare.
Effective privacy and information security programs start with attention to governance. These eight guidelines will help establish and measure privacy and information security structure and processes.
Despite the last-minute changes, MOON implementation went smoothly for many hospitals. But the full impact won't be visible until hospitals can determine how, and to what extent, the MOON will play into audits.
Ochsner Clinic Foundation began its ambulatory clinical documentation excellence journey in 2004, when Medicare implemented its Hierarchical Condition Categories (HCC). Since HCCs affect patients’ Risk Adjustment Factor scores, and ultimately reimbursement for the care required to treat sicker patients, Ochsner needed to determine the best way to ensure annual HCC capture for all patients across its vast system.
