Editor's note: The following is adapted from the HCPro book The HIPAA Omnibus Rule: A Compliance Guide for Covered Entities and Business Associates, by Kate Borten, CISSP, CISM, president of The Marblehead Group in Marblehead, Mass. To learn more about the book, go to www.hcmarketplace.com.
HIM directors can always do more to gear up for the super transition into ICD-10 next year. In fact, one way you can begin preparing is to pinpoint specific elements in ICD-9 that already exist in the record and will be documentation and coding musts once the new code set arrives.
Chasing down information on incomplete records can be overwhelming and a lost cause. What do you do when a medical record is incomplete 30 days after discharge (or 14 in California's case) and thus does not meet regulatory standards? Do you file it away without an answer to an open query or a signature from the practitioner? What if the responsible practitioner retired, expired, or is no longer practicing at your facility? Are you doing everything you can to get most deficiencies completed prior to the patient being discharged?
One task that almost every healthcare organization is going to have to tackle to comply with the HIPAA omnibus final rule is amending its Notice of Privacy Practices (NPP).
