UK HealthCare's Chief Compliance Officer R. Brett Short knew he was in for a rough day as soon as he saw the email from his organization's privacy officer.
To accurately interpret and code physician documentation, the HIM department must employ a quality clinical documentation improvement (CDI) program and an effective query process. Building upon these programs is integral to the success of the HIM department, especially where ICD-10 is concerned, said Deborah Lantz, RHIA, during HCPro's audio conference "Auditing Documentation for ICD-10: Steps to Take Now to Prepare Physicians and Staff." Lantz is the director of HIM at St. Charles Hospital in Port Jefferson, N.Y., and an AHIMA-certified ICD-10 trainer.
The release of CMS' 2014 inpatient prospective payment system (IPPS) final rule was a major game changer for hospitals. While you may be caught up in understanding and applying the 2-midnight rule for inpatient admissions, it's important to remember that the final rule also brings about significant changes to quality of care. We discussed these issues and their impact on the hospital landscape during HCPro's September 10 audio conference "2014 IPPS Final Rule Explained."
For many people, the new year brings the promise of a fresh start, which is one of the reasons why we often make New Year's resolutions. These resolutions date back to ancient Babylonian times, when people would make resolutions to gods during the vernal equinox. But for HIM professionals, a New Year's resolution often means establishing and abiding by organizational timelines, training your workforce, and updating technology.
Physicians and nurses tell patients how to take their medications before they leave the hospital. But many patients find these instructions confusing and may not really understand what medications they're taking, why they are taking them, or how to take them properly. The result: They take the medications incorrectly-or not at all-and end up back in the hospital.
Last month, CMM outlined the new CMS 2014 inpatient prospective payment system (IPPS) guidelines, which revised inpatient admission standards (see correction on p. 4). This month we're going to offer some tips to assist you to help physicians document accurately, and inform you about some other changes that will affect the way case managers do business when it comes to meeting the new standard.
