In severity and risk adjustment, defining acute kidney disease, specifically acute renal failure (ARF) and its synonym, acute kidney injury (AKI), are confounding issues for physicians, coders, and quality specialists. When do patients with elevated creatinine levels or oliguria have ARF or AKI, a major complication and comorbidityunder MS-DRGs? How do ARF, AKI, and other terms, such as acute renal insufficiency or azotemia, factor in risk adjustment?
If you’ve been outsourcing your transcription but think there might be a better way to meet your needs in-house, you may want to take another look at some other options. You may have more than you realize.
Incidents involving paper records and desktop computers are second and third most common on the growing list of privacy breaches reported on the OCR website. (The No. 1 reason for privacy breaches re-mains the loss or theft of laptop computers and other portable devices. Briefings on HIPAA looked at ways to prevent those types of privacy breaches in the June issue.)
It may be too early to start intensive ICD-10-CM training for your coding team, but now is a good time for your coders to at least become familiar with features of the new system.
Regardless of the safeguards in place in any electronic document management system (EDMS), sometimes a document ends up in the wrong patient’s record. It was a reality in the paper world, and it is a reality in the scanned record world. Obviously, it was easier to rectify in the paper environment. So how does one address this issue with a hybrid electronic record?
When it comes to release of information (ROI), it may seem that exceptions are the rule. But you must know when you can and cannot release information to protect the privacy of your facility’s patients.
