The Joint Commission's September 2015 Perspectives encourages "hospitals to design systems to ensure accurate and complete medical records." Although this is not a new concept, it becomes more important as more hospitals' medical records become electronic while still maintaining a certain amount of paper documentation.
HIM Briefings (formerly Medical Records Briefing) asked HIM and release of information (ROI) professionals about their ROI practices for its first quarterly benchmarking survey of 2016. (The survey was completed in October 2015.) We introduced several new questions this year about the medical record itself as well as ROI practices.
CMS finalized its proposals regarding the 2-midnight rule, including moving responsibility for rule enforcement and education from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
The 2016 OPPS final rule includes the first negative payment update for the system, but CMS also listened to commenters' suggestions to make a variety of proposals less onerous either operationally or financially.
Providers often struggle with modifiers‑even those they've had available to report for many years‑due to the unique scenarios they face at their facilities, staffing changes, and/or unclear or lacking authoritative guidance.
