Legible.Complete.Dated, timed, signed, and authenticated.That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
Facilities that hold regular interdisciplinary care coordination rounds often say such meetings save time. However, the rounds can turn from time-savers to time-wasters if the matters discussed do not stay on topic or drag on.
Organizations need to determine whether they have fully implemented the Security Rule. The HIPAA Security Rule has been around for a while, but many organizations have not implemented all of its requirements.
Managing the changeover to ICD-10 may be so completely overwhelming for some HIM directors and managers that just getting started is the most difficult part.
CMS’ rules for properly applying condition code 44 are hard enough to understand, but when it comes to putting those rules into practice, things can get even more difficult.
