While it can be challenging to define your organization's legal health record (LHR), one health system in Denver is proving that collaboration and perseverance can lead to an effective LHR and EHR.
Coding and documentation should tell a patient's complete story. With the greater specificity in ICD-10, organizations should be better able to capture these stories, and the respiratory codes, listed in Chapter 10: Diseases of the Respiratory System (J00?J99), are no exception.
More than ever before, HIM is being recognized as an enterprise profession important to ambulatory, acute, and postacute settings. A good example of the transformation is HIM's involvement in CMS' risk adjustment and Hierarchical Condition Category coding system.
The HIPAA Security Rule requires implementing risk management tools and techniques to adequately and effectively safeguard ePHI. Risk analysis and management provides the foundation for an organization's Security Rule compliance efforts, and reinforces its strategy to protect the confidentiality, integrity, and availability of vital information.
With quarterly code updates and other regulatory changes from CMS throughout the year, the chargemaster coordinator has to constantly monitor the healthcare landscape, but the final few months of the year remain the most challenging.
