Q: In our pharmacy dispensing system, we can enter free-form notes for certain records such as a patient record, prescription records, and physician records. This field is used to enter notes that are customer service?focused and not treatment- or payment-related in nature. Would these notes be considered PHI, and would record retention requirements apply to these notes?
For approximately 10 years, HIMB has been gathering data about the HIM profession through its annual salary survey. This survey often gives us a glimpse into the responsibilities of HIM professionals, but focuses primarily on the education, experience, and salary of those in the HIM field.
Time and again, the salary survey reveals that HIM directors and managers are wearing many hats and asked to oversee an increasing number of tasks. In an effort to dig a bit deeper into HIM departments, HIMB conducted its first HIM roles and responsibilities survey.
More than half of respondents were HIM directors (26%) or managers (25%), whereas the remaining 49% held other revenue cycle positions. Of the latter group, 50% were coders and 29% were CDI specialists. Responses also came in from transcriptionists, privacy officers, compliance officers, revenue integrity professionals, and consultants.
HIM demographics
The plurality of respondents work in acute care hospitals (55%) and critical access hospitals (17%) or have a corporate position at a multi-system hospital (8%). Other settings represented in the survey include long-term acute care hospitals, psychiatric/behavioral health hospitals, skilled nursing facilities, ambulatory surgery centers, and physician practices.
The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based outcomes linked to payment under these programs.
Effective October 1, 2017, performance for cost and quality measures in the HRRP, HVBP, and HACRP will impact up to 6% of your hospital's inpatient acute Medicare fee-for-service reimbursement.
So, where to begin? First, become familiar with the measure specifications and risk-adjustment methodologies, in addition to existing CMS provided reports on historical performance, to gain insights into your organization's clinical documentation and coding vulnerabilities.
The May 2016 issue of Perspectives outlined 225 hospital requirements from the accreditation manual?nine from the Information Management (IM) chapter and five from the Record of Care, Treatment and Services (RC) chapter?that have been deleted. This initiative is part of the Joint Commission's project REFRESH and improving the survey process.
The Medicare Reporting and Returning of Self-Identified Overpayments final rule (81 Fed. Reg. 7654‑7684), which became effective March 14, is designed to implement Section 1128J(d) of the Social Security Act, which was established under Section 6402(a) of the Affordable Care Act, effective March 23, 2010.
