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.
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.
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."
Healthcare providers are used to regularly changing guidelines and regulations that drastically alter their processes for coding and billing. Despite few guideline changes since 2008, drug administration still frequently causes confusion because of all the necessary factors to properly document, code, and bill the services.
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.
It's a brave new world out there for business associates (BA). BAs needed to comply with the HIPAA Security Rule and the use and disclosure provisions of the Privacy Rule in February 2010 as a result of the HITECH Act. However, the OCR held off on any enforcement activities-that is, until recently.
