For years we have heard that EHRs improve the quality of clinical documentation in the medical record. While this is absolutely true in terms of legibility, it may not be so true otherwise.
Coding productivity will decrease at least initially with the switch to ICD-10-CM/PCS. Coders will also need complete, accurate documentation to take advantage of the new code set's increased specificity. So HIM and coding managers need to know how productive their coders are and the extent of their clinical knowledge base, as well as how accurately and completely physicians are documenting.
The staff at St. Francis Hospital-the Heart Center in Roslyn, NY, recognize that ICD-10 is more than a one-person job, which is why Elizabeth Heller, RHIA, HIM director, and Adelaide M. La Rosa, RN, BSN, CCDS, clinical documentation improvement (CDI) program director, are cochairing efforts.
Jean Stone, RHIT, CCS, has never met some of the coders who report directly to her. She has, however, spoken with them by phone, and in some cases, she has seen their wedding or other photographs. This is because nearly all members of her department work remotely.
To take a proactive approach to the RAC process, you will need to assess your current level of financial risk. You can do this internally or with the help of external resources. There are many good risk evaluation software tools on the market for hospitals and health systems; there are also consultants who specialize in reviewing hospitals' claims for proper coding and documentation to assess overall compliance risk and make suggestions for corrections. Once you identify and quantify your risk, you can begin to take action to mitigate the impact of a RAC audit of past claims and to improve your systems to avoid being out of compliance in the future.
Throughout 2011 we are including special content in honor of MRB's 25th year. This month we reached out to some long-time readers who have been on board since MRB's early years, including some who have read every single issue! Read on to find out what they had to say.
