Hardly a week goes by in the healthcare field without another announcement of a regulatory change, delay, or new initiative. Technology innovation seems to outpace our ability to absorb change or install the latest update on various systems and software applications.
HIM professionals are at the center of a shift from a paper-based to an electronic healthcare environment. As healthcare organizations work toward Meaningful Use attestation, there are standards that can help HIM professionals ensure that their electronic records are interoperable.
Organizations often struggle to finalize charts after discharge so they can be coded in a timely manner, but this process can be completed efficiently with direction from HIM professionals and coordination between departments.
Even before ICD-10-CM was delayed until October 1, 2015, the quality of physician documentation to accommodate the new code set was a top concern for the healthcare industry.
Do your coders ever feel as if they work more hours than most coders? Or perhaps they think their compensation is lower than other coders across the country? Have you ever wondered how your coders compare to the average coder?
Q: I work in long-term care and I am familiar with the language in HIPAA regulations regarding requests for electronic copies of medical records for a reasonable fee according to community standards. However, my company does not maintain its medical records in electronic form, nor do we presently have the capability of converting our paper records into electronic format. Our state legislature addressed the issue of "reasonable charges and community standards" by state statute in 2006 by providing a formula for every medical provider to follow state-wide for copy charges regarding paper copies.
The ICD-10 delay forced many healthcare organizations to rethink their ICD-10 staffing and implementation plans. Baptist Health System in Birmingham, Alabama, devised a plan to prepare for the one-year delay of ICD-10 by revising its budget and relying on new graduates to fill coder positions.
In a concerted effort to move healthcare payments to a system of "quality over quantity," CMS finalized policies that greatly expanded packaging for outpatient providers in the 2015 OPPS final rule (www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf). It also introduced complexity adjustments with comprehensive ambulatory payment classifications (C-APCs).
