HIM directors can always do more to gear up for the super transition into ICD-10 next year. In fact, one way you can begin preparing is to pinpoint specific elements in ICD-9 that already exist in the record and will be documentation and coding musts once the new code set arrives.
Chasing down information on incomplete records can be overwhelming and a lost cause. What do you do when a medical record is incomplete 30 days after discharge (or 14 in California's case) and thus does not meet regulatory standards? Do you file it away without an answer to an open query or a signature from the practitioner? What if the responsible practitioner retired, expired, or is no longer practicing at your facility? Are you doing everything you can to get most deficiencies completed prior to the patient being discharged?
One task that almost every healthcare organization is going to have to tackle to comply with the HIPAA omnibus final rule is amending its Notice of Privacy Practices (NPP).
In a time when so much attention is focused on issues such as cyber security and the dangers posed from evolving technology, it's easy to forget the HIPAA basics, such as the need for workforce members not to gossip or chitchat about patients with other staff members or people in the community.
In January 2013, CMS introduced 42 therapy functional reporting G codes (nonpayable). These G codes are to be reported in conjunction with therapy services (physical, occupational, and speech). CMS also introduced seven complexity/severity modifiers to be used with these G codes.
