HIM directors must renew efforts in the new year to ensure the effectiveness of EHR quality monitors. With increased attention on HIPAA 5010 requirements and instituting ICD-10, focusing on the quality of your medical records may sometimes take a backseat to other priorities. However, as inaccurate data tends to affect all areas of HIM-not to mention patient care-taking an active role in developing quality measures will ultimately save time and money in the long run and help ensure quality care for patients. Developing a plan for managing data integrity before issues occur will free up time for HIM staff to focus on other initiatives.
Self-administered drugs present a significant issue for coders, especially when considering how they may or may not be covered by Medicare Part B. In many instances, payers may consider a drug to be self-administered in some circumstances but not in others. As a result, coders must pay special attention to how these drugs are used within their setting.
Q We're struggling with nursing documentation of stop times for IV infusions (e.g., piggybacks and hydration). The nurses also inconsistently document a patient's return to the unit from diagnostics. We know that CMS now allows us to use average times for common services, and we're interested in considering this approach at my organization. Can you share additional specifics?
In total, the AMA added 60 new codes throughout the surgery section of the 2012 CPT® Manual, 18 of which appear in the cardiovascular and respiratory system subsections. The AMA also revised 86 codes and deleted 48 codes in the surgery section.
Coders can find the largest number of new codes in the pathology and laboratory section of the 2012 CPT® Manual. The AMA added a total of 103 new codes, 101 of which denote Tier 1 and Tier 2 molecular path-ology procedures.