Inpatient coding professionals are used to DRG systems where all of the diagnoses and procedures map to a single DRG. So they may not look for additional procedures and services to report outside of that DRG.
Q: My facility no longer registers patients under aliases, but will allow them to opt out of the patient directory. However, opting out of the registry will not exclude our patients from the operating room (OR) list. At one time, the facility's CEO received the daily OR list with full patient names so he could visit board members, donors, or others whom he knows at our facility. HIM changed this practice so that patients' names would not be on the OR schedule provided to the CEO. The CEO took this matter to the hospital attorney, who said the names could be included because the use of PHI by the CEO to determine whether and when a patient visit is appropriate is permitted by HIPAA as it is part of healthcare operations. Is it a violation of HIPAA for the CEO to use PHI to track patients in this manner?
While organizations should focus on performing regular risk assessments and analyses, there are also other ways in which they must review their systems for compliance. Often, these other evaluations are overlooked despite their value, says Kevin Beaver, CISSP, an information security consultant in Atlanta. In particular, organizations should be careful not to forget about performing vulnerability assessments and penetration tests, which are components of an overall risk assessment or analysis, says Beaver, who is an editorial advisory board member for SHCC's sister publication Briefings on HIPAA.
The implementation of Comprehensive APCs (C-APCs) in the 2015 OPPS final rule likely wasn't a huge surprise to most providers, given CMS discussed this concept in the 2014 final rule and indicated it expected to implement it the following year.
Editor's note: With the increased specificity required for ICD-10-CM coding, coders need a solid foundation in anatomy and physiology. To help coders prepare for the upcoming transition, we will provide occasional articles about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation. This month's article addresses the anatomy of the urinary system.
