HIM Briefings

Dear colleagues:

Even though it is still two and a half years away, it’s not too early to begin preparation for the October 1, 2013, transition from ICD-9-CM to ICD-10-CM/PCS. There’s much to do in concert with HIM professionals to develop the knowledge base and documentation infrastructure essential to accurate ICD-10-CM/PCS code capture and reporting.

As part of our yearlong celebration of MRB’s 25th birthday, this month we are featuring an interview with the newsletter’s founder, Jennifer Cofer Flanagan. Flanagan is also the founder of Opus Communications (now HCPro) and previously served as president of AHIMA (formerly the American Medical Record Association), as well as director of communications and professional practices for the organization. She is currently on the board of trustees for the North Shore Medical Center based in Salem, MA.

Many organizations develop physician documentation tip sheets based on the clinical topics appropriate to their specific facility. Some handouts are a simple piece of paper developed by a clinical documentation improvement team, whereas others are laminated, elaborately formatted cards from consulting companies distributed as part of the initial implementation program. Several samples donated by members of the Association of Clinical Documentation Improvement Specialists (ACDIS) are available on its  website at www.hcpro.com/acdis. (See p. 11 for a sample.)

On October 1, 2013, all HIPAA-covered entities must implement ICD-10-CM for all diagnoses and ICD-10-PCS for all inpatient hospital procedures.

Use this quiz to test your coding staff members on the new CPT codes that went into effect January 1.

The codes, they are a-changin’. 

“In my opinion, [ICD-10 implementation] is the biggest change in healthcare since the implementation of DRGs back in the early ’80s,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA. McCall and Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, spoke during HCPro’s November 18 audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.”

The last thing you need is more to do, but when it comes to preparing your HIM department for EHR go-live, an ounce of prevention is worth a pound of cure.

Many of the nation’s hospitals now have clinical documentation improvement (CDI), management, or integrity programs. They are designed to help physicians improve the documentation of diagnostic or procedural information in inpatient medical records so that the documentation meets the needs of the coding process. There are good things that can come out of these programs, but there can also be bad things.

HIPAA privacy officers don’t have eyes in the back of their heads. Nor can they be everywhere at once. But they can increase their ability to monitor compliance by sharing the responsibility with other staff members.