HIM Briefings

It will take time for coders to become comfortable translating terminology used in physician documentation to root operation terminology used in ICD-10-PCS, according to Lolita M. Jones, RHIA, CCS, independent consultant in Fort Washington, MD, who spoke during HCPro’s November 18, 2010, audio conference, “ICD-10-PCS Surgery Coding: Understand and Apply Five Medical Surgical Root Operations.” But Jones thinks coders will get there eventually.

In 2010, HCPro’s Revenue Cycle Institute conducted its second annual in-depth study on RAC preparedness among healthcare providers. The results are now in: RAC audits have picked up, but preparation and education are still under way for many, and HIM plays an important role.

I promised in a previous “Standards of the month” column that I would address Joint Commission standard MM.04.01.01 (orders for medication are clear and accurate), as this standard made it onto the 2010 top 10 list of standards with which hospitals were noncompliant. In fact, 30% of hospitals failed to comply with it.

After 10 years, the requirements for signatures on lab requisitions are still in flux; CMS published the latest change to the lab signature requirements in the 2011 Medicare Physician Fee Schedule (MPFS) final rule published in the Federal Register November 29, 2010.

Use this tool to test staff members’ HIPAA knowledge.

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.