Ensuring detailed documentation isn't important only with respect to documenting medical necessity. Case managers should also ensure physicians are including enough information in patient records to help them accurately estimate LOS, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, PCS, FCS, C-CDIS, CCDS, an independent health information management consultant in Madison, Wis.
In October 2012, Medical Records Briefing (MRB) asked HIM managers and directors about their ICD-10 implementation efforts for our first quarterly benchmarking survey of the year.
There's a popular saying that states, "Too much of a good thing can be bad for you." I believe that's never been truer than now when it comes to EMR documentation.
It has been quite a year in the privacy world, hasn't it? The OCR website has reported 500 breaches of unsecured PHI affecting 500 or more individuals, totaling more than 12 million patients. There has been an increase in HIPAA-related criminal sentences involving jail time. And private lives are no longer private.
One thing is certain: You don't want to wait until you receive a notification letter from OCR before you begin preparing for a HIPAA audit, says Dena Boggan, CPC, CMC, CCP, HIPAA privacy/security officer at St. Dominic Jackson (Miss.) Memorial Hospital.
