With the latest edition of the NCCI Manual, effective January 1, CMS does not introduce any new guidance for recurring coding trouble areas including modifier -59 (distinct procedural service) usage and injection and infusion services, but some new clarifications could aid coding departments.
This week’s note is about the new rule establishing a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies.
This week’s updates include the January 2016 update of the hospital OPPS; April 2016 quarterly update for the DME, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP); and more!
CMS did not change the logic for comprehensive APCs (C-APC) or complexity adjustments in the 2016 OPPS final rule, but did add 10 new C-APCs for 2016 in addition to the 25 established for the first time for 2015.
I first attended a lecture on the "upcoming" ICD-10 changes that were expected in 1991 (when the rest of the world started transitioning). On October 1, 2015, a mere 24 years and countless lectures later, the U.S. finally adopted ICD-10 (via ICD-10-CM and PCS, which are both unique to the U.S. at this time).
Q: What is the recommendation for retaining hard copies of medical records once they have been transferred to an EMR system?
A: This varies quite a bit depending on your storage capabilities and state retention laws. I am aware of some organizations that keep these records for 3?6 years (until the statute of limitations has run out), but this is a very conservative approach. I have also seen six months and one month. I would suggest ensuring you have a rigorous scanning quality control process to reassure yourself that you in fact have the scanned documents and they are readable. I would recommend that you keep the hard copies for at least one month after scanning. You might also want to consult legal counsel on this matter.
Editor's note: Simons, director of health information and privacy officer at Maine General Medical Center in Augusta, answered these questions. She is also a HIM Briefings advisory board member. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Send your questions related to HIPAA compliance to Editor Jaclyn Fitzgerald at jfitzgerald@hcpro.com.
