HIM Briefings

One of the most important aspects of documenting your evaluation and treatment of inpatients in the medical record is providing the verbiage that meets your goals for describing your patient. When you provide the right words, the coders assign the right codes.

The electronic Program for Evaluating Payment Patterns Electronic Report (PEPPER) contains data for hospitals on MS-DRGs and discharges at high risk for payment errors. Per the opening paragraph of the 2010 PEPPER User’s Guide:

As part of a compliance program, a hospital should conduct regular audits to ensure charges for Medicare services are correctly documented and billed. PEPPER can help guide the hospital’s auditing and monitoring activities.

ARRA brought us an expanded version of HIPAA. Along with it came the clear message that if the last time you visited your HIPAA policies and procedures was April 15, 2005, you have a problem.

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?