HIM Briefings

Many hospitals seem to struggle with inconsistencies in the quality of their physicians’ history and physical exam (H&P) documentation, particularly when it comes to allergies and current medications. And the medical staff at Central Peninsula Hospital in Soldotna, AK, believed they were no exception, according to Marianne Dailey, RHIT, CHP, CPHQ, HIM director and privacy officer at the hospital.

Motivating staff to produce more when recognition of superior performance is limited or nonexistent is difficult. Remember that incentives need not be financial; they can be monetary or non-monetary, individual- or team-based. Organizations may offer them regularly or sporadically based on variable or consistent criteria.

The Affordable Health Care for America Act, passed in late March, may leave many HIM directors scratching their heads. After all, sweeping reform must mean change is coming, but what will it look like?

Are you where you should be in terms of the ICD-10 implementation process? If you aren't sure whether your hospital is on track, or if you know you aren't where you need to be, consider taking advantage of a customizable timeline, courtesy of the Workgroup for Electronic Data Interchange (WEDI)/North Carolina Healthcare Information and Communications Alliance (NCHICA) Timeline Initiative.

Are you where you should be in terms of the ICD-10 implementation process? If you aren't sure whether your hospital is on track, or if you know you aren’t where you need to be, consider taking advantage of a customizable timeline, courtesy of the Workgroup for Electronic Data Interchange (WEDI)/North Carolina Healthcare Information and Communications Alliance (NCHICA) Timeline Initiative.

The many CPT and HCPCS modifiers can leave coders dazed and confused when it comes to appropriately appending them. Unfortunately, hard-coding certain modifiers into your chargemaster is not the answer. However, having coders take the time to brush up on them regularly can certainly help.

Despite the numerous jokes on the subject, physician illegibility is no laughing matter, and Kaweah Delta Medical Center knows it. That’s why, after The Joint Commission found problems with the facility’s physician legibility, Kaweah Delta developed a plan to address the problem.

Although The Joint Commission has not focused on the ongoing record review (ORR) process during surveys and hospitals have not received recommendations for improvement in this area, ORR is still vital to the success of any survey. ORR can also be useful for clarifications when a hospital feels a recommendation isn’t substantiated.