HIM Briefings

Use this Q&A to test staff members’ HIPAA knowledge.

I have received several questions related to my “Standards of the month” column about history and physical (H&P) reports. 

I thought it would be a good idea to clarify two specific issues these inquiries raised: 1) the requirements for H&P examinations for moderate sedation, and 2) allowing anesthesiologists to complete the update to the H&P report prior to surgery.

On July 8, HHS released a proposed rule to modify the HIPAA Privacy, Security, and Enforcement Rules, extending HIPAA compliance requirements to subcontractors of business associates (BA) and strengthening patient rights to health information privacy. The rule is available for viewing at http://edocket.access.gpo.gov/2010/pdf/2010-16718.pdf.

According to a July HCPro survey of approximately 500 healthcare providers, 56% have already received medical record requests and 40% have had money recouped by a RAC.

HHS softened some of its proposed requirements for healthcare entities to become meaningful users of EHRs in a final rule released July 13.

Dear colleagues:

In severity and risk adjustment, defining acute kidney disease, specifically acute renal failure (ARF) and its synonym, acute kidney injury (AKI), are confounding issues for physicians, coders, and quality specialists. When do patients with elevated creatinine levels or oliguria have ARF or AKI, a major complication and comorbidity  under MS-DRGs? How do ARF, AKI, and other terms, such as acute renal insufficiency or azotemia, factor in risk adjustment?

If you’ve been outsourcing your transcription but think there might be a better way to meet your needs in-house, you may want to take another look at some other options. You may have more than you realize.

It may be too early to start intensive ICD-10-CM training for your coding team, but now is a good time for your coders to at least become familiar with features of the new system.

Regardless of the safeguards in place in any electronic document management system (EDMS), sometimes a document ends up in the wrong patient’s record. It was a reality in the paper world, and it is a reality in the scanned record world. Obviously, it was easier to rectify in the paper environment. So how does one address this issue with a hybrid electronic record?