HIM Briefings

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?

When it comes to release of information (ROI), it may seem that exceptions are the rule. But you must know when you can and cannot release information to protect the privacy of your facility’s patients.

As physicians, we are quite aware of the severity of illness of the cancer patients we treat. However, we frequently are not cognizant of the elements of their diseases that need documentation or clarification in the medical record to accurately portray the complexity of those patients. I’d like to discuss some of the issues that surgeons, oncologists, family physicians, and pediatricians might face that need some attention in documentation.

The transition to ICD-10 is not in any way the kind of transition we made from ICD-8 to ICD-9, nor is it a simple matter of training coders and implementing a revised encoding system. This will probably be one of the biggest transitions hospitals and HIM directors and coders have seen in many years.

Medically unnecessary services and incorrectly coded items had the highest amounts of RAC overpayments collected in the demonstration project, according to CMS.

There is good news, but also a little bad news, about history and physical (H&P) reports coming out of changes for 2010.