If there's one conclusion that OCR is ready to draw from the 115 HIPAA compliance audits conducted last year, it's that there is plenty of room for improvement.
Everyone knows that CCs and MCCs are under scrutiny these days. However, that doesn't mean hospitals should err on the side of caution when reporting these conditions. William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., provides several tips that coders can employ to look for clinical evidence in the record before querying for these targeted conditions.
HIM directors must revisit and potentially refine processes for patient record restriction requests and requests for electronic copies of medical records because of the HHS HIPAA omnibus final rule.
If the October 1, 2014, implementation date for ICD-10-CM and ICD-10-PCS is not altered by the time this is published, there will be 18 months left until the transition.
