Having recently returned from teaching the HCPro Accreditation Specialist Boot Camp, I was reminded that our medical staffs continue to have challenges with documentation requirements that have existed at least as long as most of us have been HIM professionals. I thought it was a good time to remind HIM professionals and their medical staff of 12 documentation requirements that are still a major focus during Joint Commission surveys, and persist in being a record completion challenge.
Q: The company I work for has long debated what to do about medical records that are sent out on CDs. We concluded that since paper records could not be encrypted, we shouldn't have to worry about encrypting the CDs.
I was recently discussing the state of EHRs in regard to the poor quality of the documentation with a colleague who has been a practicing HIM professional for more than 35 years and currently works for a large group of hospitals as the coding director.
Developing a strong denial management program may be one of the best ways to minimize the productivity and financial losses anticipated with the transition to ICD-10. By determining a baseline for denials and proactively identifying denial trends, organizations can efficiently resolve issues and reduce costs. An effective denial management program will help organizations to track, trend, resolve, and ultimately prevent denials.
After years of wavering and waffling, ICD-10 was finally set to become a reality on the first of October. The extent to which this new set of codes for medical diagnoses and inpatient hospital procedures will affect you depends largely on how your role is structured, says Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida.
Compliance with the 2-midnight rule has been tricky for many organizations?and things aren't expected to get easier anytime soon. The 2016 OPPS proposed rule may bring some additional tweaks to the 2-midnight rule (see related story, "Proposed OPPS rule suggests tweaksto 2-midnight rule," in the September issue of CMM), and education and enforcement may change hands from Recovery Auditors to Quality Improvement Organizations.
