It is no longer enough to confirm that a diagnosis is documented somewhere in the record. The documentation must also clearly demonstrate the clinical severity of the patient’s illness.
Some of the most significant HIPAA risks stem from the often overlooked processes where protected health information is collected, handled, and disposed of.
Coding for alcohol- and drug-related disorders requires careful attention to both clinical terminology and the structure of the ICD-10-CM classification system.
As artificial intelligence (AI) moves deeper into healthcare operations, from clinical documentation to coding and decision support, HIM leaders are being pulled into a more central, critical role.
Delays in patient access to records remain one of the most visible—and enforceable—failures under HIPAA. Learn where organizations are most vulnerable today.
As hospitals and health systems continue to acquire physician practices and bring providers under their umbrella, traditional coding models are starting to show their limits.
Federal regulators continue to signal that delayed patient access to medical records is one of the most visible and enforceable areas of HIPAA compliance.
Most CDI programs focus their educational efforts on key documentation elements, but it's also important to instruct staff on terms to avoid in the medical record.
