Q: Is it permissible to write down a patient's pending exams (e.g., MRI, ultrasound) on the patient boards located by the patient's bed in his or her room even if that patient has a roommate?
Ready or not, Phase 2 of OCR's HIPAA audit program is nearly ready to begin, and healthcare organizations and their business associates (BA) should be prepared to open their books to federal regulators.
As more hospitals adopt EHRs over paper records, the amount of data stored electronically steadily increases. However, the usefulness of this data diminishes if it does not translate to meaningful information that hospitals can use for operations surrounding registration, treatment, billing, coding, and research.
A few days after Briefings on APCs conducted the interview that appeared in last month's issue with W. Jeff Terry, MD, an AMA delegate from Mobile, Alabama, the AMA and CMS announced an accord regarding ICD-10.
In a joint announcement, the organizations said that CMS would not audit or deny Part B physician fee schedule claims for one year after ICD-10-CM implementation due to lack of specificity. While physicians will still be responsible for meeting medical necessity and LCD and NCD requirements, valid ICD-10-CM codes that include the appropriate first three characters will be sufficiently specific for Medicare claims.
