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.
A case manager at a meeting described how the family of a patient was pressuring her to change the patient from outpatient services to inpatient status. If she didn't help, the family pleaded, the patient would face higher costs for postacute care. The case manager bragged about how she held the line, despite the tears. However, others in the room didn't think the details of the case were as black and white as the case manager claimed. And some wondered whether "holding the line" at any cost is really what a case manager should be doing.
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.
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.
I am updating the notice of privacy practices and accounting of disclosures policy for my organization. Do any of the new, finalized rules indicate that the accounting of disclosures covers disclosures for treatment, payment, and healthcare operations?
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.
