CMS designates certain procedures as inpatient-only and identifies them using CPT codes. Hospitals normally only use CPT codes for outpatient coding, so this may be confusing for coders who use ICD-9-CM Volume 3 codes for inpatient procedures. Coders need to know which procedures are on the inpatient-only list to monitor compliance with this rule as they apply inpatient procedure codes.
Since portions of the reproductive system use some of the same structures as the urinary system, including the urethra, codes for conditions involving both male and female reproductive systems appear in Chapter 14 of ICD-10-CM, Diseases of the Genitourinary System.
Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for at least 20 days or the case is an outlier.
Coding for sepsis requires a strong knowledge of ICD-9-CM coding guidelines, as well as complete and accurate documentation. That's not a surprise to any coding professional. They need those two elements to successfully code any medical record.
While it can be challenging to define your organization's legal health record (LHR), one health system in Denver is proving that collaboration and perseverance can lead to an effective LHR and EHR.
Q: I am familiar with the HIPAA Security Rule requiring information system review audits. Are there any HIPAA Privacy Rule requirements?other than to perform audits?that require the examination of inappropriate access for an alleged breach? Currently, our security team performs monthly information system review audits and issues reports to leadership on a quarterly basis. Will this suffice, or are there audits that the privacy team should perform as well?
