HIM Briefings

My experience in ICD-10-CM documentation and coding integrity is that many physicians know in their heads what is wrong with their patients; however, they have not been taught to “think with ink” in describing their patients' illness in the EHR using ICD-10-CM’s language to ensure proper coding.

RC.01.01.01 is one standard that just won’t go away. The first half of 2017 (January–June) standards compliance data was published in the September issue of The Joint Commission’s Perspectives, and RC.01.01.01 made the list again. This means that the standard has been on the top 10 list for at least the last five years, along with other frequent flyers such as Environment of Care, Life Safety, and Infection Prevention.

Having just witnessed nature wreak havoc with back-to-back hurricanes, I feel it’s important to take a few minutes to remind everyone of the importance of Plan B—the backup plan. Let’s look at some real examples of how HIM professionals can be proactive to prevent chaos when unexpected events occur.

Patient care continues to move from the inpatient setting to outpatient. With this change, the challenge of securing comprehensive documentation that articulates the services rendered and the patient care provided now needs to extend across the care continuum.

Cognitive computing will transform the future of clinical care as we know it in three direct ways: making data accessible, making it approachable, and making it actionable.

Outsourcing some HIM functions is common at many organizations. The decision might initially be spurred by staffing shortages or budgetary concerns, but many outsourcing arrangements become long-term projects. 

The new ICD-10-CM codes for FY 2018, effective October 1, 2017, represent significant changes in some of our documentation and coding practices. Review the changes to the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting (the Guidelines), which must be embraced if our documentation, coding, and billing is to withstand compliance scrutiny from outside auditors and accountability agents.

This month's Q&A answers readers' questions on patient record access and more.

Managing and maintaining the chargemaster requires sound, tested strategies and tactics.