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.
The top finding in Joint Commission surveys for the first half of 2013 should be no surprise for HIM professionals. For the last three years, RC.01.01.01 has been No. 1 on the top 10 list of most frequently cited standards in Joint Commission surveys. The good news is that RC.01.01.01 is the only standard from the Record of Care, Treatment and Services (RC) chapter to make the list. The bad news is that this standard and some of its EPs will most likely continue to be a challenge.
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.
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 an occasional article about specific anatomical locations and body parts as part of a larger series for ICD-10-CM preparation.
The September 23 compliance deadline for most of the provisions of the HIPAA omnibus rule has come and gone. But for covered entities (CE) and business associates (BA), now is not the time to take your foot off the gas pedal.
Every healthcare organization should develop and implement a policy and a well-defined process that provides guidance for managing incident and breach response.
